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 preparing to administer an IM injection that is irritating to the subcutaneous tissue, what is the best action to prevent tracking of the medication?

• A. Use a small gauge needle
• B. Apply ice on the injection site
• C. Administer at a 45° angle
• D. Use the Z-track technique

Correct answer: D

Rationale: The Z-track technique is the best action to prevent tracking of the medication when administering an IM injection that is irritating to the subcutaneous tissue. This technique involves pulling the skin to the side before administering the injection and then releasing the skin after the injection. By doing so, a zig-zag pathway is created, preventing the medication from leaking into the subcutaneous tissue and reducing irritation. Options A, B, and C are incorrect. Using a small gauge needle may not prevent tracking of the medication. Applying ice on the injection site or administering at a 45° angle does not specifically address preventing tracking of the medication in cases where the injection is irritating to the subcutaneous tissue.

3. After a walk-in client enters the clinic with a chief complaint of abdominal pain and diarrhea, the nurse takes the client’s vital signs. What phase of the nursing process is being implemented by the nurse?

• A. Assessment
• B. Diagnosis
• C. Planning
• D. Implementation

Correct answer: A

Rationale: In this scenario, the nurse is performing the assessment phase of the nursing process. Assessment involves collecting data, which includes obtaining vital signs, to identify the client's health status and needs. This step is crucial for the nurse to gather information that will guide further decision-making in the nursing process. Choice B, 'Diagnosis,' would involve analyzing the collected data to identify the client's health problems. Choice C, 'Planning,' would be developing a plan of care based on the assessment findings. Choice D, 'Implementation,' is the phase where the nurse carries out the plan of care developed during the planning phase.

4. A client complains of difficulty swallowing when the nurse tries to administer capsule medication. Which of the following measures should the nurse take?

• A. Dissolve the capsule in a glass of water
• B. Break the capsule and give the contents with applesauce
• C. Check the availability of a liquid preparation
• D. Crush the capsule and place it under the tongue

Correct answer: C

Rationale: When a client has difficulty swallowing capsule medication, the nurse should check the availability of a liquid preparation. This is a safer approach and ensures that the medication's integrity is maintained, providing an alternative form that is easier for the client to take. Dissolving the capsule in water (choice A) may alter the medication's effectiveness, breaking the capsule and mixing the contents with applesauce (choice B) is not recommended as it may cause an unpleasant taste, and crushing the capsule and placing it under the tongue (choice D) can be unsafe and affect the medication's absorption.

5. A healthcare professional is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the professional recognize?

• A. Confusion
• B. Pale skin
• C. Bradycardia
• D. Hypotension

Correct answer: B

Rationale: Pale skin is an early manifestation of hypoxemia due to decreased oxygenation of the blood. The skin may appear pale as the body redirects blood flow to vital organs in response to low oxygen levels. Confusion, bradycardia, and hypotension may occur as hypoxemia worsens, but pale skin is one of the initial signs that healthcare professionals should recognize when assessing a client experiencing respiratory distress.

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