Nursing Elites

1. A client with chronic heart failure is admitted with shortness of breath and a new onset of confusion. Which intervention should the nurse implement first?

• A. Obtain a neurological assessment.
• B. Administer oxygen therapy.
• C. Monitor the client's urine output.
• D. Obtain an electrocardiogram (ECG).

Correct answer: A

Rationale: The correct answer is to obtain a neurological assessment. In a client with chronic heart failure presenting with confusion, the priority is to assess neurological status to rule out potential causes such as hypoxia or other complications. Administering oxygen therapy (Choice B) is important but assessing the neurological status takes precedence in this scenario. Monitoring urine output (Choice C) and obtaining an ECG (Choice D) may be necessary but are not the initial priority when a client presents with confusion alongside shortness of breath.

2. A client with heart failure is prescribed furosemide (Lasix). Which assessment finding requires immediate intervention?

• A. Heart rate of 60 beats per minute
• B. Blood pressure of 100/60 mmHg
• C. Crackles in the lungs
• D. Presence of a new murmur

Correct answer: C

Rationale: The correct answer is C. Crackles in the lungs indicate fluid overload, a common issue in heart failure patients. Immediate intervention is necessary to prevent worsening heart failure symptoms and potential complications. A heart rate of 60 beats per minute and a blood pressure of 100/60 mmHg are within normal ranges for many individuals and do not typically require immediate intervention in this context. The presence of a new murmur may be important to monitor but is not the priority when crackles in the lungs suggest fluid overload.

3. The nurse reviews the laboratory findings of a client with an open fracture of the tibia. The white blood cell (WBC) count and erythrocyte sedimentation rate (ESR) are elevated. Before reporting this information to the healthcare provider, what assessment should the nurse obtain?

• A. Appearance of wound
• B. Pain level
• C. Presence of fever
• D. Mobility status

Correct answer: A

Rationale: The correct answer is A: Appearance of wound. Elevated WBC and ESR levels suggest a possible infection in the client with an open fracture. Assessing the wound's appearance is crucial to evaluate for signs of infection, such as redness, warmth, swelling, or drainage. By assessing the wound first, the nurse can provide important information to the healthcare provider regarding the potential infection, which may require immediate intervention. Choices B, C, and D are important assessments in caring for a client with an open fracture; however, in this scenario, the priority is to assess the wound for signs of infection due to the elevated WBC and ESR levels.

4. A client with a history of rheumatoid arthritis is prescribed methotrexate. Which laboratory value should the nurse monitor closely?

• A. Liver function tests
• B. Complete blood count
• C. Serum creatinine
• D. Prothrombin time

Correct answer: C

Rationale: Serum creatinine should be closely monitored in a client receiving methotrexate, as the medication can cause nephrotoxicity. Monitoring serum creatinine levels helps assess kidney function and detect potential nephrotoxic effects of methotrexate. Liver function tests (Choice A) are important to monitor for hepatotoxicity caused by methotrexate. While methotrexate can cause bone marrow suppression, leading to anemia, leukopenia, and thrombocytopenia, monitoring a complete blood count (Choice B) is essential but not the priority in this case. Prothrombin time (Choice D) is not typically affected by methotrexate therapy and is not the primary laboratory value to monitor in this situation.

5. The nurse is caring for a client with a history of myocardial infarction who is experiencing chest pain. Which diagnostic test should the nurse anticipate preparing the client for first?

• A. Electrocardiogram (ECG)
• B. Chest X-ray
• C. Arterial blood gases (ABGs)
• D. Echocardiogram

Correct answer: A

Rationale: Corrected Rationale: An electrocardiogram (ECG) should be performed first to assess for cardiac ischemia in a client with a history of myocardial infarction and chest pain. An ECG provides immediate information about the heart's electrical activity, helping to identify changes indicative of cardiac ischemia or infarction. Chest X-ray (Choice B) is not the initial diagnostic test for assessing chest pain related to myocardial infarction. Arterial blood gases (Choice C) are used to assess oxygenation and acid-base balance but are not the primary diagnostic test for myocardial infarction. An echocardiogram (Choice D) may provide valuable information about cardiac structure and function, but it is not the first-line diagnostic test for acute chest pain in a client with a history of myocardial infarction.

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