Nursing Elites

1. A healthcare provider is assessing a client who has left-sided heart failure. Which of the following should the healthcare provider identify as a manifestation of pulmonary congestion?

• A. Frothy, pink sputum
• B. Jugular vein distention
• C. Weight gain
• D. Bradypnea

Correct answer: A

Rationale: Pulmonary congestion is a common manifestation of left-sided heart failure. When the left side of the heart fails, blood backs up into the lungs, leading to pulmonary congestion. This can result in symptoms such as frothy, pink-tinged sputum due to the presence of blood in the respiratory secretions. Jugular vein distention, weight gain, and bradypnea are also associated with heart failure, but frothy, pink sputum specifically indicates pulmonary congestion in this scenario.

2. When is the most appropriate time for obtaining a sputum specimen for culture?

• A. Early in the morning
• B. After the patient eats a light breakfast
• C. After aerosol therapy
• D. After chest physiotherapy

Correct answer: A

Rationale: Obtaining a sputum specimen early in the morning is the most appropriate time because secretions have accumulated overnight. This timing provides the best sample with the least contamination, leading to more accurate culture results and aiding in diagnosing respiratory infections effectively.

3. What is a nurse's role in health promotion?

• A. Conducting health risk appraisals
• B. Educating clients to be effective health consumers
• C. Implementing worksite wellness programs
• D. None of the above

Correct answer: B

Rationale: A nurse plays a crucial role in health promotion by educating clients to be effective health consumers. This involves empowering individuals to make informed decisions about their health, access appropriate healthcare services, and engage in healthy behaviors to prevent illness and promote well-being. The other choices are not entirely accurate in describing the primary role of a nurse in health promotion. While nurses may conduct health risk appraisals and implement worksite wellness programs as part of their responsibilities, their central focus is on educating and empowering individuals to take control of their health.

4. Which chamber of the heart receives oxygenated blood from the lungs?

• A. Left atrium
• B. Right atrium
• C. Left ventricle
• D. Right ventricle

Correct answer: A

Rationale: The correct answer is A, the left atrium. The left atrium receives oxygenated blood from the lungs through the pulmonary veins. This blood is then pumped into the left ventricle before being circulated throughout the body. The right atrium, represented by choice B, actually receives deoxygenated blood from the body through the vena cava. Choices C and D, the left ventricle and right ventricle respectively, are chambers involved in pumping blood out of the heart to the body and lungs, rather than receiving blood from the lungs.

5. In the emergency department, a nurse is assessing a client involved in a motor vehicle crash. Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg, heart rate 124/min, respirations 38/min, temperature 38.6 C (101.4 F), and SaO2 92% on room air. What action should the nurse take first?

• A. Obtain a chest X-ray.
• B. Prepare for chest tube insertion.
• C. Administer oxygen via high-flow mask.
• D. Initiate IV access.

Correct answer: C

Rationale: In this scenario, the client is presenting with signs of respiratory distress, including absent breath sounds, dyspnea, and a low SaO2 level. The priority action should be to improve oxygenation by administering oxygen via a high-flow mask. This intervention aims to increase the oxygen supply to the client's lungs, helping to address the hypoxemia. Once oxygenation is optimized, further interventions, such as obtaining a chest X-ray, preparing for chest tube insertion, or initiating IV access, can be considered based on the client's condition and healthcare provider's orders.

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