Nursing Elites

1. A client with multiple sclerosis is experiencing fatigue. What is the nurse's priority intervention?

• A. Encourage the client to increase physical activity.
• B. Encourage the client to take rest breaks during activities.
• C. Administer a stimulant medication to reduce fatigue.
• D. Advise the client to use energy conservation techniques.

Correct answer: D

Rationale: The correct answer is D: Advise the client to use energy conservation techniques. Energy conservation techniques are crucial in managing fatigue in multiple sclerosis. These techniques involve prioritizing activities, pacing oneself, and taking rest breaks to prevent overexertion, which can exacerbate fatigue. Encouraging the client to increase physical activity (choice A) may worsen fatigue if not done with proper energy conservation. Taking rest breaks during activities (choice B) is important but falls secondary to teaching energy conservation techniques. Administering a stimulant medication to reduce fatigue (choice C) should not be the priority as non-pharmacological interventions like energy conservation should be attempted first.

2. The nurse is caring for a client with pancreatitis who is receiving total parenteral nutrition (TPN). Which assessment finding requires immediate intervention by the nurse?

• A. Blood glucose level of 200 mg/dL
• B. The client reports feeling weak and shaky
• C. The TPN bag is 5% dextrose
• D. The client reports feeling thirsty

Correct answer: B

Rationale: The correct answer is B. Weakness and shakiness can indicate hypoglycemia, a potential complication of TPN. Immediate intervention is necessary to assess blood glucose levels and provide treatment as needed. Choice A is incorrect because a blood glucose level of 200 mg/dL is within an acceptable range and does not require immediate intervention. Choice C is incorrect as a 5% dextrose TPN bag is a standard concentration. Choice D is also incorrect as feeling thirsty is not a critical assessment finding requiring immediate intervention in this context.

3. After placing a stethoscope to auscultate S1 and S2 heart sounds, what should the nurse do to check for an S3 heart sound?

• A. Switch to the diaphragm of the stethoscope to hear any abnormal sounds
• B. Listen with the bell of the stethoscope at the same location
• C. Listen at a different location over the aortic area
• D. Switch to the apical area and reassess for S3 sounds

Correct answer: B

Rationale: To assess for an S3 heart sound, the nurse should listen with the bell of the stethoscope. An S3 heart sound is often low-pitched and best heard with the bell. Choice A is incorrect because switching to the diaphragm is not ideal for detecting low-pitched sounds like an S3. Choice C is incorrect as the S3 heart sound is best heard over the apex of the heart, not the aortic area. Choice D is incorrect because moving to the apical area is appropriate, but the nurse should specifically use the bell of the stethoscope to listen for S3 sounds.

4. Prior to administering warfarin to a client with a history of atrial fibrillation, what lab result should the nurse review?

• A. White blood cell count.
• B. Prothrombin time (PT) and International Normalized Ratio (INR).
• C. Hemoglobin and hematocrit.
• D. Blood urea nitrogen (BUN) and creatinine.

Correct answer: B

Rationale: The correct answer is B: Prothrombin time (PT) and International Normalized Ratio (INR). These lab values are crucial for monitoring the effectiveness of warfarin, an anticoagulant medication. PT measures the time it takes for blood to clot, while INR standardizes these results. Ensuring the client's PT/INR levels are within the therapeutic range is essential to prevent clotting or excessive bleeding. Choices A, C, and D are incorrect as they are not directly related to monitoring warfarin therapy in a client with atrial fibrillation.

5. An S3 heart sound is auscultated in a client in her third trimester of pregnancy. What intervention should the nurse take?

• A. Perform a 12-lead electrocardiogram
• B. Document in the client's record
• C. Notify the healthcare provider immediately
• D. Assess for signs of heart failure

Correct answer: B

Rationale: An S3 heart sound is often a normal finding in pregnant women due to increased blood volume and cardiac output. The nurse should document the finding as part of the routine assessment unless accompanied by other abnormal symptoms. Performing a 12-lead electrocardiogram (Choice A) is unnecessary for a normal S3 heart sound in pregnancy. Notifying the healthcare provider immediately (Choice C) is premature and may lead to unnecessary interventions. Assessing for signs of heart failure (Choice D) is not indicated as an isolated S3 heart sound is typically benign in pregnancy.

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