Nursing Elites

1. A nurse assesses a client who has a history of heart failure. Which question should the nurse ask to assess the extent of the client's heart failure?

• A. Do you have trouble breathing or chest pain?
• B. Are you able to walk upstairs without fatigue?
• C. Do you awake with breathlessness during the night?
• D. Do you have new-onset heaviness in your legs?

Correct answer: B

Rationale: Clients with a history of heart failure generally have negative findings, such as shortness of breath. The nurse needs to determine whether the client's activity is the same or worse, or whether the client identifies a decrease in activity level. Trouble breathing, chest pain, breathlessness at night & peripheral edema are symptoms of heart failure, but do not provide data that can determine the extent of the client's heart failure.

2. A client had an evacuation of a subdural hematoma. Which of the following actions should the nurse take first?

• A. Observe for cerebrospinal fluid (CSF) leaks from the evacuation site.
• B. Assess for an increase in temperature.
• C. Check the oximeter.
• D. Monitor for manifestations of increased intracranial pressure.

Correct answer: C

Rationale: When caring for a client who had an evacuation of a subdural hematoma, the nurse's priority is to check the oximeter. Monitoring oxygen saturation is crucial to ensure adequate tissue oxygenation, especially after such a procedure. This assessment helps in early detection of hypoxemia, which can be detrimental to the client's recovery. While observing for CSF leaks, assessing for temperature changes, and monitoring for signs of increased intracranial pressure are important, checking the oximeter takes precedence to address immediate oxygenation needs.

3. After an open lung biopsy, a nurse assesses a client. Which assessment finding is matched with the correct intervention?

• A. Client states he is dizzy. Nurse applies oxygen and pulse oximetry.
• B. Client's HR is 55 beats/min. Nurse withholds pain medication.
• C. Client has reduced breath sounds. Nurse calls the physician immediately.
• D. Client's RR is 18 breaths/min. Nurse decreases the oxygen flow rate.

Correct answer: C

Rationale: After an open lung biopsy, a potential complication is pneumothorax, often indicated by reduced or absent breath sounds. The nurse should promptly notify the physician to address this serious issue and ensure timely intervention.

4. A client is caring for a postoperative client on the surgical unit. The client's blood pressure was 142/76 mm Hg 30 minutes ago and is now 88/50 mm Hg. What action by the nurse is best?

• A. Call the Rapid Response Team.
• B. Document and continue to monitor.
• C. Notify the primary care provider.
• D. Repeat blood pressure measurement in 15 minutes.

Correct answer: A

Rationale: In this scenario, the significant drop in blood pressure indicates a potential emergency situation. The correct action is to call the Rapid Response Team (RRT) to ensure prompt intervention and prevent further deterioration that could lead to respiratory or cardiac arrest. It is crucial to act swiftly in response to such a critical change in vital signs to provide the client with the necessary care and support.

5. A college health nurse interprets the peak expiratory flow rate for a student who has asthma and finds that the student is in the yellow zone of his asthma action plan. The nurse should not base her actions on which of the following information?

• A. The student should use his quick-relief inhaler.
• B. The student's asthma is not well controlled.
• C. The student's peak flow is 50% to 80% of his best peak flow.
• D. The student needs to go to the hospital

Correct answer: D

Rationale: In an asthma action plan, the yellow zone indicates caution and signals a need to monitor symptoms closely. When a student is in the yellow zone, the appropriate action is to follow the prescribed steps, which typically include using a quick-relief inhaler and closely monitoring peak flow. Going to the hospital is usually reserved for severe asthma exacerbations in the red zone. Therefore, the information that the student needs to go to the hospital is not typically appropriate when the student is in the yellow zone.

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