Nursing Elites

1. A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect?

• A. Peripheral edema.
• B. Cough with frothy sputum.
• C. Jugular vein distention.
• D. Dependent edema.

Correct answer: C

Rationale: The correct answer is C: Jugular vein distention. In left-sided heart failure, the left ventricle fails to efficiently pump blood to the body, causing increased pressure in the pulmonary circulation. This increased pressure can lead to symptoms like jugular vein distention, as blood backs up in the pulmonary circulation and causes congestion. Choices A, B, and D are incorrect: Peripheral edema is more commonly associated with right-sided heart failure, cough with frothy sputum is a sign of pulmonary edema which can occur in left-sided heart failure but is not as specific as jugular vein distention, and dependent edema is also more indicative of right-sided heart failure due to fluid retention and increased venous pressure in the systemic circulation.

2. A nurse is preparing to administer blood to a client. Which of the following actions should the nurse take first?

• A. Check the client's identification bracelet.
• B. Obtain the client's vital signs.
• C. Initiate the transfusion slowly over the first 15 minutes.
• D. Verify the client's blood type and Rh factor.

Correct answer: D

Rationale: The correct answer is to verify the client's blood type and Rh factor first before administering blood. This is crucial to ensure compatibility and prevent transfusion reactions. Checking the client's identification bracelet (Choice A) is important but should come after verifying blood type. Obtaining vital signs (Choice B) and initiating the transfusion slowly (Choice C) are important steps but verifying blood type is the priority to ensure safe blood administration.

3. A nurse is reviewing the laboratory values of a client who has diabetic ketoacidosis (DKA). Which of the following findings should the nurse report to the provider?

• A. Potassium 4.2 mEq/L
• B. Glucose 250 mg/dL
• C. Bicarbonate 20 mEq/L
• D. Sodium 135 mEq/L

Correct answer: B

Rationale: The correct answer is B. A glucose level of 250 mg/dL indicates hyperglycemia, which is expected in DKA. However, in the context of DKA management, persistent or worsening hyperglycemia can indicate inadequate treatment response or complications, necessitating further monitoring and intervention. Potassium levels are crucial in DKA due to the risk of hypokalemia, but a level of 4.2 mEq/L is within the normal range. Bicarbonate levels are typically low in DKA, making a value of 20 mEq/L consistent with the condition. Sodium levels of 135 mEq/L are also within normal limits and not a priority for immediate reporting in the context of DKA.

4. A nurse is caring for a client who is receiving total parenteral nutrition. Which of the following laboratory findings should the nurse report to the provider?

• A. Prealbumin level of 20 mg/dL
• B. Serum albumin level of 3.5 g/dL
• C. Serum sodium level of 138 mEq/L
• D. Blood glucose level of 120 mg/dL

Correct answer: D

Rationale: The correct answer is D because a blood glucose level of 120 mg/dL falls within the normal range. A low serum albumin level, as mentioned in choice B, should be reported as it may indicate malnutrition. Choices A and C are within normal ranges and would not typically require immediate reporting.

5. A nurse is providing teaching to a client who has GERD. Which of the following instructions should the nurse include?

• A. Lie flat for 30 minutes after meals.
• B. Avoid lying down after meals.
• C. Drink hot liquids with meals.
• D. Consume a high-carbohydrate snack at bedtime.

Correct answer: B

Rationale: The correct answer is B: 'Avoid lying down after meals.' This instruction is important for clients with GERD to prevent acid reflux. Lying down after meals can worsen GERD symptoms by allowing stomach acid to flow back into the esophagus. Choices A, C, and D are incorrect. Choice A is incorrect because lying flat after meals can increase the risk of acid reflux. Choice C is incorrect because hot liquids may aggravate GERD symptoms. Choice D is incorrect because consuming a high-carbohydrate snack at bedtime can also trigger acid reflux in individuals with GERD.

Similar Questions