Nursing Elites

1. A nurse is assessing a client with pericarditis. Which of the following findings is the priority for the nurse to report?

• A. Paradoxical pulse
• B. Dependent edema
• C. Pericardial friction rub
• D. Substernal chest pain

Correct answer: A

Rationale: A paradoxical pulse is a sign of cardiac tamponade, a life-threatening complication of pericarditis that requires immediate intervention. It results from decreased cardiac output due to increased pressure in the pericardial sac. Reporting this finding promptly allows for timely treatment to prevent further deterioration. Dependent edema and substernal chest pain are common in pericarditis but are not as urgent as a paradoxical pulse. A pericardial friction rub is a classic finding in pericarditis and indicates inflammation but is not as critical as a paradoxical pulse.

2. A client has been prescribed ferrous sulfate. Which instruction should the nurse include?

• A. Take with meals
• B. Take with a glass of orange juice
• C. Take at bedtime
• D. Take with milk

Correct answer: B

Rationale: The correct instruction for a client prescribed ferrous sulfate is to take it with a glass of orange juice. Vitamin C, found in orange juice, enhances the absorption of iron, making it more effective. Taking ferrous sulfate with meals, at bedtime, or with milk can decrease its absorption and effectiveness, so these options are incorrect.

3. A client who is at 24 weeks of gestation is being taught about the signs of preterm labor. Which of the following should the nurse include?

• A. Sudden weight loss
• B. Regular contractions
• C. Shortness of breath
• D. Vaginal spotting

Correct answer: B

Rationale: The correct answer is B: Regular contractions. Regular contractions before 37 weeks of gestation are a significant sign of preterm labor. It is essential for clients to be aware of this symptom and report it promptly to their healthcare provider. Choices A, C, and D are incorrect because sudden weight loss, shortness of breath, and vaginal spotting are not typical signs of preterm labor. Teaching clients about the specific signs of preterm labor can help in early detection and intervention, ultimately improving outcomes for both the client and the baby.

4. In the nursing process, the evaluation phase is used to determine:

• A. Value of the nursing intervention
• B. Accuracy of problem identification
• C. Quality of the plan of care
• D. Degree of outcome achievement

Correct answer: D

Rationale: The evaluation phase of the nursing process is used to determine the degree of outcome achievement. It assesses whether the goals and outcomes set during the planning phase were met. Choice A is incorrect because it focuses on the worth of the intervention rather than the achievement of outcomes. Choice B is incorrect as it pertains to the assessment phase where problems are identified. Choice C is incorrect as it refers to the planning phase where the care plan is developed, not evaluated.

5. A healthcare professional is preparing to administer a dose of potassium chloride. Which of the following actions should the healthcare professional take?

• A. Administer rapidly
• B. Dilute the medication before administration
• C. Give it as a bolus
• D. Administer it intramuscularly

Correct answer: B

Rationale: The correct action when administering potassium chloride is to dilute the medication before administration. Potassium chloride is a highly concentrated solution that can cause irritation and potential complications if not properly diluted. Administering it rapidly (choice A) can lead to adverse effects. Giving it as a bolus (choice C) or administering it intramuscularly (choice D) are inappropriate routes for potassium chloride administration and can result in harm to the patient.

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