Nursing Elites

1. A nurse is assessing a client who is receiving packed RBCs. Which of the following findings indicate fluid overload?

• A. Low back pain
• B. Dyspnea
• C. Hypotension
• D. Thready pulse

Correct answer: B

Rationale: The correct answer is B: Dyspnea. Dyspnea, or difficulty breathing, is a common sign of fluid overload in a client receiving packed RBCs. When fluid accumulates in the lungs due to overload, it can lead to respiratory distress. This finding requires prompt intervention to prevent further complications. Choices A, C, and D are incorrect: A) Low back pain is not typically associated with fluid overload; C) Hypotension refers to low blood pressure and is not a typical finding in fluid overload; D) Thready pulse may indicate poor perfusion but is not a direct indicator of fluid overload.

2. A client is being discharged two days after a mastectomy. Which of the following instructions should the nurse include?

• A. Wear a tight-fitting bra for support.
• B. Avoid lifting heavy objects for at least 6 weeks.
• C. Sleep on the affected side to promote healing.
• D. Begin arm exercises 24 hours after surgery.

Correct answer: B

Rationale: The correct answer is to instruct the client to avoid lifting heavy objects for at least 6 weeks after a mastectomy. This is important to prevent complications and promote proper healing. Choice A is incorrect because tight-fitting bras can increase the risk of lymphedema and discomfort. Choice C is incorrect as sleeping on the affected side can cause discomfort and interfere with healing. Choice D is incorrect as initiating arm exercises too soon after surgery can strain the surgical site and hinder recovery.

3. A client is preparing advance directives. Which of the following statements by the client indicates an understanding of advance directives?

• A. I cannot change my instructions once I have signed them.
• B. My doctor will need to approve my advance directives.
• C. I need a witness to sign my advance directives.
• D. I have the right to refuse treatment.

Correct answer: D

Rationale: The correct answer is D: 'I have the right to refuse treatment.' This statement shows an understanding of advance directives because they allow individuals to specify their treatment preferences in advance, including the right to refuse treatment. Choices A, B, and C are incorrect. Choice A is inaccurate as individuals can update or change their advance directives at any time. Choice B is incorrect because while a doctor may discuss advance directives with the client, approval is not required for the directives to be valid. Choice C is also incorrect as a witness is typically required to verify the client's signature, not the other way around.

4. A nurse is assessing a client who has a chest tube and notes continuous bubbling in the water seal chamber. Which of the following actions should the nurse take?

• A. Continue to monitor the client.
• B. Clamp the chest tube.
• C. Replace the drainage system.
• D. Apply a dressing over the insertion site.

Correct answer: D

Rationale: The correct action for the nurse to take when continuous bubbling is noted in the water seal chamber of a chest tube is to apply a dressing over the insertion site. Continuous bubbling indicates an air leak, and applying a dressing helps manage this issue by providing a seal. Clamping the chest tube or replacing the drainage system is not appropriate in this situation as it can lead to complications such as tension pneumothorax or inadequate drainage of the pleural space.

5. A nurse is reviewing the medical record of a client who is receiving heparin to treat deep vein thrombosis (DVT). Which of the following findings should the nurse report to the provider?

• A. aPTT of 38 seconds
• B. Hemoglobin of 15 g/dL
• C. Platelet count of 80,000/mm3
• D. INR of 1.0

Correct answer: C

Rationale: A platelet count of 80,000/mm3 is below the normal range and should be reported to the provider due to the risk of bleeding. Heparin can cause a rare but serious side effect known as heparin-induced thrombocytopenia, leading to a decrease in platelet count and an increased risk of bleeding. The aPTT of 38 seconds, hemoglobin of 15 g/dL, and an INR of 1.0 are within normal ranges and not directly concerning in this scenario. Platelet count is crucial to monitor in clients receiving heparin therapy to ensure adequate clotting function and prevent bleeding complications.

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