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 teaching a client with tuberculosis, which statement should the nurse include?

• A. You will need to continue taking the multi-medication regimen for 4 months.
• B. You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication.
• C. You will need to remain hospitalized for treatment.
• D. You will need to wear a mask at all times.

Correct answer: B

Rationale: Monitoring the effectiveness of tuberculosis medication is crucial to ensure the treatment is working properly. Regular sputum samples help in assessing the response to the medication. This monitoring can guide adjustments in the treatment plan if needed. Options A and C are incorrect as they do not reflect essential aspects of tuberculosis treatment. Option D is not a standard recommendation for tuberculosis treatment and may lead to misconceptions.

3. A client is being instructed on how to perform pursed-lip breathing. Which of the following should be included in the plan of care?

• A. Take quick breaths upon inhalation.
• B. Place your hand over your stomach.
• C. Take a deep breath in through your nose.
• D. Puff your cheeks upon exhalation.

Correct answer: C

Rationale: Pursed-lip breathing is a breathing technique that involves inhaling slowly through the nose and exhaling gently through pursed lips. This technique helps improve breathing efficiency and can be beneficial for individuals with respiratory conditions. Instructing the client to take a deep breath in through the nose is essential for proper execution of pursed-lip breathing, making choice C the correct answer.

4. Which natural body defense plays an active role in preventing infection?

• A. Yawning
• B. Body hair
• C. Hiccupping
• D. Rapid eye movements

Correct answer: B

Rationale: Body hair plays an active role in preventing infection by acting as a filter to block pathogens. It helps to prevent harmful substances from entering the body through the skin, providing a physical barrier against potential infections.

5. A client experiencing acute dyspnea and diaphoresis reports anxiety and difficulty breathing. Vital signs include HR 117/min, respirations 38/min, temperature 38.4 C (101.2 F), and blood pressure 100/54 mm Hg. What should the nurse prioritize?

• A. Notify the provider.
• B. Administer heparin via IV infusion.
• C. Administer oxygen therapy.
• D. Obtain a spiral CT scan.

Correct answer: C

Rationale: In a client with acute dyspnea, diaphoresis, tachycardia, tachypnea, fever, and hypotension, the priority is to ensure adequate oxygenation. Administering oxygen therapy helps improve oxygenation levels and stabilize the client's condition. This intervention takes precedence over notifying the provider, administering heparin, or obtaining a CT scan, as oxygen therapy addresses the client's immediate need for respiratory support.

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