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. A patient requires augmentation of labor. Which of the following conditions should the nurse recognize as a contraindication to the use of oxytocin?

• A. Diabetes mellitus
• B. Shoulder presentation
• C. Postterm with oligohydramnios
• D. Chorioamnionitis

Correct answer: C

Rationale: Postterm pregnancy with oligohydramnios is a contraindication for the use of oxytocin due to the increased risk of uterine hyperstimulation and fetal distress. Oxytocin can further stress the fetus in this scenario, potentially leading to adverse outcomes. Therefore, it is crucial for the nurse to recognize this contraindication to ensure the safety of both the mother and the baby during labor.

3. A client is recovering from an acute myocardial infarction that occurred 3 days ago. Which of the following instructions should the nurse include in the care plan?

• A. Perform an ECG every 12 hours.
• B. Place the client in a supine position while resting.
• C. Draw a troponin level every 4 hours.
• D. Obtain a cardiac rehabilitation consultation.

Correct answer: D

Rationale: After an acute myocardial infarction, cardiac rehabilitation is crucial for the client's recovery. It helps improve the client's overall cardiovascular health, reduces the risk of future cardiac events, and promotes a healthy lifestyle. The other options do not directly address the importance of cardiac rehabilitation in the client's recovery process.

4. What is the primary purpose of handwashing?

• A. To promote hand circulation
• B. To prevent the transfer of microorganisms
• C. To avoid touching the client with a dirty hand
• D. To provide comfort

Correct answer: B

Rationale: The primary purpose of handwashing is to prevent the transfer of microorganisms. Proper hand hygiene helps reduce the risk of spreading harmful bacteria and viruses, thus promoting overall health and preventing infections. Choice A is incorrect as handwashing primarily focuses on cleanliness rather than promoting circulation. Choice C is incorrect as it implies that the main concern is avoiding client discomfort rather than preventing infection. Choice D is incorrect as while handwashing can be comforting in some situations, its primary purpose is not to provide comfort but to maintain hygiene.

5. Which of the following actions will most likely lead to a break in the sterile technique for respiratory isolation?

• A. Opening the patient’s window to the outside environment
• B. Turning on the patient’s room ventilator
• C. Opening the door of the patient’s room leading into the hospital corridor
• D. Failing to wear gloves when administering a bed bath

Correct answer: D

Rationale: Failure to wear gloves during a bed bath can potentially introduce pathogens, compromising the sterile technique necessary for respiratory isolation. Proper hand hygiene and personal protective equipment are crucial to prevent the transmission of infectious agents in such settings.

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