Nursing Elites

1. A client with heart failure is experiencing shortness of breath and swelling in the legs. What is the nurse's priority intervention?

• A. Administer prescribed diuretics
• B. Place the client in a supine position
• C. Restrict fluid intake immediately
• D. Increase the client's sodium intake

Correct answer: A

Rationale: The correct answer is A: Administer prescribed diuretics. Diuretics are prescribed to reduce fluid overload in clients with heart failure. By promoting urine output, diuretics help alleviate symptoms like shortness of breath and swelling. While placing the client in a supine position can help with breathing and fluid redistribution, administering diuretics takes precedence as it directly addresses fluid overload. Restricting fluid intake immediately may be necessary in some cases, but the immediate priority is to administer diuretics. Increasing the client's sodium intake would worsen fluid retention and is contraindicated in heart failure.

2. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who has been experiencing increasing shortness of breath. Which finding requires immediate intervention?

• A. A respiratory rate of 26 breaths per minute
• B. Use of accessory muscles for breathing
• C. Barrel chest appearance
• D. A pulse oximetry reading of 88%

Correct answer: D

Rationale: A pulse oximetry reading of 88% indicates hypoxemia, which requires immediate intervention to improve oxygenation. Hypoxemia can lead to serious complications if not addressed promptly. While a respiratory rate of 26 breaths per minute and the use of accessory muscles for breathing are concerning in COPD, they do not indicate an immediate life-threatening situation. Similarly, a barrel chest appearance is a common finding in COPD and does not require urgent intervention compared to the critical need to address hypoxemia.

3. A client with diabetic ketoacidosis (DKA) is receiving an insulin infusion. Which finding indicates that the treatment is effective?

• A. Potassium level of 4.0 mEq/L.
• B. Blood glucose level of 180 mg/dL.
• C. Urine output of 50 mL/hour.
• D. Absence of ketones in the urine.

Correct answer: D

Rationale: The correct answer is D: Absence of ketones in the urine. In a client with diabetic ketoacidosis (DKA) receiving an insulin infusion, the absence of ketones in the urine indicates that ketoacidosis is resolving. This is a crucial finding as it shows that the insulin therapy is effectively addressing the metabolic imbalance causing DKA. Choices A, B, and C are incorrect: A potassium level of 4.0 mEq/L is within normal range but does not directly reflect the resolution of DKA; a blood glucose level of 180 mg/dL, while improved, is still high and does not specifically indicate the resolution of ketoacidosis; urine output of 50 mL/hour is within normal limits but does not directly point to the resolution of DKA.

4. A client is receiving continuous intravenous heparin for a deep vein thrombosis. Which laboratory result should the nurse monitor to ensure therapeutic heparin levels?

• A. International normalized ratio (INR)
• B. Activated partial thromboplastin time (aPTT)
• C. Hemoglobin
• D. Platelet count

Correct answer: B

Rationale: The activated partial thromboplastin time (aPTT) is the most accurate measure of heparin's therapeutic effect. Heparin increases the time it takes for blood to clot, and the aPTT helps determine whether the dose is within the desired range for anticoagulation therapy. Monitoring the INR, hemoglobin, or platelet count is not specific to assessing therapeutic heparin levels and may not reflect the anticoagulant effect of heparin.

5. A client with schizophrenia is experiencing auditory hallucinations. What is the nurse's best response?

• A. Encourage the client to ignore the voices and stay focused on reality.
• B. Acknowledge the client's feelings and ask what the voices are saying.
• C. Redirect the conversation to help distract the client from the hallucinations.
• D. Offer reassurance that the voices cannot harm the client.

Correct answer: B

Rationale: The best response for a client with schizophrenia experiencing auditory hallucinations is to acknowledge the client's feelings and ask what the voices are saying. This approach helps build rapport with the client, demonstrates empathy, and allows the nurse to assess the content of the hallucinations. Understanding the content is crucial to determine whether the client is at risk of harm. Encouraging the client to ignore the voices (Choice A) may invalidate their experience. Redirecting the conversation (Choice C) may not address the underlying issue of the hallucinations. Offering reassurance (Choice D) without understanding the content may overlook potential risks.

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