Nursing Elites

1. A client with a history of chronic heart failure is admitted with symptoms of dyspnea and fatigue. What initial intervention should the nurse prepare to implement?

• A. Administration of IV diuretics
• B. Oxygen therapy
• C. Bed rest
• D. Dietary consultation

Correct answer: B

Rationale: The correct initial intervention for a client with chronic heart failure presenting with dyspnea and fatigue is oxygen therapy. Oxygen therapy can help relieve dyspnea and improve oxygen saturation levels, which are crucial in managing heart failure exacerbations. Administering IV diuretics may be necessary later to address fluid overload, but oxygen therapy takes precedence in addressing the immediate respiratory distress. Bed rest and dietary consultation are important aspects of care for heart failure patients, but in this scenario, oxygen therapy is the priority to improve the client's respiratory status.

2. A client with a history of chronic obstructive pulmonary disease (COPD) is prescribed oxygen therapy at 2 liters per minute via nasal cannula. What is the most important instruction the nurse should provide?

• A. Increase the oxygen flow rate if shortness of breath occurs
• B. Use oxygen only when experiencing shortness of breath
• C. Do not adjust the oxygen flow rate without consulting a healthcare provider
• D. Use a humidifier with the oxygen to prevent dry mucous membranes

Correct answer: C

Rationale: The most important instruction the nurse should provide to a client with COPD prescribed oxygen therapy is not to adjust the oxygen flow rate without consulting a healthcare provider. This is crucial because too much oxygen can suppress the client's respiratory drive, leading to further complications. Choice A is incorrect because increasing the oxygen flow rate without medical advice can be harmful. Choice B is incorrect as oxygen therapy should be used as prescribed, not just when symptoms occur. Choice D is incorrect as the priority is to ensure the correct oxygen flow rate rather than using a humidifier.

3. After receiving a report, the nurse receives the laboratory values for four clients. Which client requires the nurse’s immediate intervention? The client who is...

• A. Short of breath after a shower and has a hemoglobin of 8 grams
• B. Bleeding from a finger stick and has a prothrombin time of 30 seconds
• C. Febrile and has a WBC count of 14,000/mm3
• D. Trembling and has a glucose level of 50 mg/dL

Correct answer: D

Rationale: A glucose level of 50 mg/dL is indicative of hypoglycemia, which requires immediate intervention to prevent further complications. Hypoglycemia can lead to serious consequences such as altered mental status, seizures, and even coma if not promptly addressed. The other options do not present immediate life-threatening conditions that require urgent intervention. Shortness of breath with a hemoglobin of 8 grams may indicate anemia but does not require immediate intervention. Bleeding from a finger stick with a prothrombin time of 30 seconds may suggest clotting issues, which are important but not as immediately critical as hypoglycemia. Being febrile with an elevated WBC count could indicate infection, which is concerning but not as urgently critical as hypoglycemia.

4. A client begins taking an antidepressant drug during the second day of hospitalization. Which assessment is most important for the nurse to include in this client's plan of care while the client is taking the antidepressant?

• A. Appetite
• B. Mood
• C. Withdrawal
• D. Energy level

Correct answer: B

Rationale: Corrected Rationale: Monitoring the client's mood is essential when starting an antidepressant to assess for any changes or adverse effects related to the medication. Changes in mood can indicate the effectiveness of the antidepressant or potential side effects. Assessing appetite (Choice A) is important but not as crucial as monitoring mood in this context. Withdrawal symptoms (Choice C) are more relevant when discontinuing antidepressants rather than starting them. Energy level (Choice D) can be influenced by various factors and may not directly reflect the client's response to the antidepressant.

5. A client who fell 20 feet from the roof of his home has multiple injuries, including a right pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the intensive care unit (ICU). The nurse observes that the suction control chamber is bubbling at the -10 cm H20 mark, with fluctuation in the water seal, and over the past hour, 75 mL of bright red blood is measured in the collection chamber. Which intervention should the nurse implement?

• A. Increase wall suction to eliminate fluctuation in the water seal.
• B. Give blood from the collection chamber as autotransfusion.
• C. Add sterile water to the suction control chamber.
• D. Manipulate blood in tubing to drain into chamber.

Correct answer: C

Rationale: The correct intervention for the nurse to implement is to add sterile water to the suction control chamber. This action helps maintain the proper functioning of the chest tube system by regulating the negative pressure. Increasing wall suction is not recommended as it could lead to excessive negative pressure. Giving blood from the collection chamber as autotransfusion is inappropriate and poses a risk of complications such as air embolism. Manipulating blood in the tubing is also unsafe as it could introduce air into the system, increasing the risk of complications for the client.

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