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 caring for a client with an acute myocardial infarction. Which symptom requires immediate intervention?

• A. Dizziness
• B. Shortness of breath
• C. Severe chest pain
• D. Nausea and vomiting

Correct answer: C

Rationale: Severe chest pain is the hallmark symptom of an acute myocardial infarction (heart attack) and requires immediate intervention to prevent further damage to the heart muscle. Chest pain in this context is often described as crushing, pressure, tightness, or heaviness. It can radiate to the arms, neck, jaw, back, or upper abdomen. Other symptoms like dizziness, shortness of breath, nausea, and vomiting may also occur in acute myocardial infarction, but chest pain is the most critical sign requiring prompt action as it signifies inadequate blood flow to the heart muscle. Shortness of breath may indicate heart failure, while nausea and vomiting can be associated with the sympathetic response to myocardial infarction. Dizziness could result from decreased cardiac output but is not as specific to myocardial infarction as severe chest pain.

3. A client with hyperthyroidism is experiencing palpitations. What intervention should the nurse implement?

• A. Encourage the client to rest and limit activity.
• B. Administer a beta-blocker to reduce heart rate.
• C. Encourage the client to drink cool fluids.
• D. Provide the client with a cool environment.

Correct answer: B

Rationale: In clients with hyperthyroidism experiencing palpitations, administering a beta-blocker is the appropriate intervention. Beta-blockers help reduce heart rate and control symptoms in hyperthyroidism. Encouraging rest (Choice A) may be helpful but does not directly address the palpitations. Drinking cool fluids (Choice C) and providing a cool environment (Choice D) are more focused on temperature regulation and comfort, which are not the primary interventions for palpitations in hyperthyroidism.

4. The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250, and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern?

• A. Diminished bowel sounds
• B. Loss of appetite
• C. A cold, pale lower leg
• D. Tachypnea

Correct answer: C

Rationale: A cold, pale lower leg is cause for the most concern as it could indicate compromised blood circulation, potentially leading to serious complications like ischemia or thrombosis. Diminished bowel sounds, loss of appetite, and tachypnea are not directly related to the client's condition in atrial fibrillation and the heart rate discrepancy.

5. Prolonged exposure to high concentrations of supplemental oxygen over several days can cause which pathophysiological effect?

• A. Reduced cardiac output
• B. Disrupted surfactant production
• C. Hyperactivity of alveoli
• D. Increased oxygen carrying capacity

Correct answer: B

Rationale: Corrected Rationale: Prolonged exposure to high oxygen concentrations can disrupt the production of surfactant in the lungs, leading to atelectasis and other lung complications. Surfactant is essential for maintaining lung compliance and preventing alveolar collapse. Reduced cardiac output (Choice A) is not directly associated with prolonged oxygen exposure. Hyperactivity of alveoli (Choice C) is not a recognized consequence of high oxygen levels. Increased oxygen carrying capacity (Choice D) is not a pathophysiological effect of prolonged high oxygen exposure.

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