Nursing Elites

1. A nurse is assessing a client with a history of heart failure. Which of the following findings should the nurse monitor?

• A. Increased energy
• B. Peripheral edema
• C. Elevated heart rate
• D. Improved lung sounds

Correct answer: B

Rationale: The correct answer is B: Peripheral edema. In heart failure, the heart's inability to pump effectively can lead to fluid backup, causing swelling in the extremities, known as peripheral edema. Monitoring for peripheral edema is crucial as it is a common sign of worsening heart failure. Choices A, C, and D are incorrect because increased energy, elevated heart rate, and improved lung sounds are not typical findings in heart failure. Increased energy is not usually associated with heart failure, an elevated heart rate may occur as a compensatory mechanism but is not a direct sign of heart failure, and improved lung sounds are not expected in heart failure which often presents with crackles or wheezes due to pulmonary congestion.

2. A nurse is providing teaching for a client who has GERD. Which of the following assessment findings should the nurse expect to find?

• A. Shortness of breath
• B. Rebound tenderness
• C. Atypical chest pain
• D. Vomiting blood

Correct answer: C

Rationale: The correct answer is C: Atypical chest pain. GERD often presents with atypical chest pain due to acid reflux, which can mimic the symptoms of cardiac conditions but is related to the esophagus. Shortness of breath (choice A) is not a typical assessment finding in GERD. Rebound tenderness (choice B) is associated with peritoneal inflammation, not GERD. Vomiting blood (choice D) is a severe symptom that may indicate esophageal damage but is not a common assessment finding in GERD.

3. A nurse is planning care for a newly admitted adolescent client who has bacterial meningitis. Which of the following instructions is appropriate for the nurse to include in the plan of care?

• A. Initiate droplet precautions
• B. Assist the client to a supine position
• C. Perform Glasgow Coma Scale assessment every 24 hours
• D. Recommend prophylactic acyclovir for the client’s family

Correct answer: A

Rationale: The correct answer is A: 'Initiate droplet precautions.' Bacterial meningitis requires droplet precautions to prevent the spread of infection, as the bacteria can be transmitted through respiratory secretions. Choice B is incorrect because assisting the client to a supine position is not specific to the care of a client with bacterial meningitis and may not be appropriate for all clients. Choice C is incorrect because while performing Glasgow Coma Scale assessments is important in managing clients with neurological conditions, it is not directly related to preventing the spread of bacterial meningitis. Choice D is incorrect because recommending prophylactic acyclovir for the client's family is not a standard precautionary measure for preventing the spread of bacterial meningitis.

4. A nurse is preparing to administer ampicillin 500 mg in 50 mL of dextrose 5% in water (D5W) to infuse over 15 min. The drop factor of the manual IV tubing is 10 gtt/mL. How many gtt/min should the nurse set the manual IV infusion to deliver?

• A. 30 gtt/min
• B. 32 gtt/min
• C. 33 gtt/min
• D. 35 gtt/min

Correct answer: C

Rationale: Calculation: 10 gtt/mL × 50 mL ÷ 15 min = 33.33, rounded to 33 gtt/min. This ensures proper delivery of the medication over the prescribed time. Choice A is incorrect because it does not factor in the precise calculation based on the given data. Choice B is incorrect as it does not reflect the accurate rate of infusion required. Choice D is incorrect as it does not align with the correct calculation based on the drop factor and infusion parameters provided in the question.

5. A client is in the transition phase of labor. Which of the following actions should the nurse take?

• A. Assist the client to void every 3 hours
• B. Monitor contractions every 30 minutes
• C. Place the client in a lithotomy position
• D. Encourage the client to use a pant-blow breathing pattern

Correct answer: D

Rationale: Encouraging the client to use a pant-blow breathing pattern is crucial during the transition phase of labor. This phase is characterized by intense contractions and emotional responses. Pant-blow breathing helps manage pain and anxiety, providing comfort and support to the client. Voiding every 3 hours is not specific to the transition phase and may not address immediate needs. Monitoring contractions every 30 minutes is important but may not be as directly beneficial as focusing on coping mechanisms like breathing techniques. Placing the client in a lithotomy position is generally not recommended during the transition phase as it can impede progress and comfort.

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