Nursing Elites

1. A nurse is caring for a client who has right-sided heart failure. Which of the following findings should the nurse expect?

• A. Peripheral edema.
• B. JVD.
• C. Crackles in the lungs.
• D. Hypotension.

Correct answer: B

Rationale: The correct answer is B: JVD. Jugular venous distention (JVD) is a common finding in right-sided heart failure due to fluid overload. This occurs because the right side of the heart is unable to effectively pump blood, leading to congestion and increased venous pressure, which is manifested as JVD. Choices A, C, and D are incorrect. Peripheral edema (choice A) is more commonly associated with left-sided heart failure. Crackles in the lungs (choice C) are indicative of pulmonary edema, often seen in left-sided heart failure. Hypotension (choice D) is not typically seen in right-sided heart failure, as it is more commonly associated with conditions like shock or severe dehydration.

2. A nurse is caring for a client who is 3 days postoperative following a colostomy. Which of the following findings should the nurse report to the provider?

• A. Stoma that is red and moist
• B. Purulent drainage from the stoma
• C. Stoma that is dry and purple
• D. Mild swelling around the stoma

Correct answer: C

Rationale: A dry, purple stoma is abnormal and may indicate compromised blood flow, which should be reported to the provider. A red and moist stoma is a normal finding postoperatively. Purulent drainage from the stoma indicates infection and should also be reported. Mild swelling around the stoma is common in the early postoperative period and does not typically require immediate reporting.

3. A nurse is reviewing the prescription for doxazosin with a client. Which of the following should be included in the teaching?

• A. Decrease caloric intake to prevent weight gain.
• B. Increase dietary fiber to alleviate constipation.
• C. Rise slowly when sitting up from bed.
• D. Take this medication in the morning.

Correct answer: C

Rationale: The correct answer is C. Doxazosin can cause orthostatic hypotension, leading to dizziness and falls if the client rises quickly from a seated position. Instructing the client to rise slowly when sitting up from bed helps prevent these adverse effects. Choices A, B, and D are incorrect because doxazosin does not directly relate to caloric intake, dietary fiber, or a specific time of day for administration.

4. A nurse is teaching a client who has a new prescription for lisinopril. Which of the following statements should the nurse include?

• A. You should expect to develop a dry cough while taking this medication.
• B. This medication can cause a slow heart rate.
• C. You should increase your intake of foods high in potassium.
• D. You should avoid using salt substitutes while taking this medication.

Correct answer: D

Rationale: The correct statement to include when teaching a client prescribed with lisinopril is that they should avoid using salt substitutes while taking this medication. Lisinopril can cause hyperkalemia, which is an elevated level of potassium in the blood. Therefore, using salt substitutes that contain potassium can worsen this condition. Choices A, B, and C are incorrect because lisinopril is not typically associated with causing a dry cough or a slow heart rate, and increasing potassium intake can be harmful in the presence of lisinopril-induced hyperkalemia.

5. A healthcare professional is preparing to administer an autologous blood product to a client. Which of the following actions should the healthcare professional take to identify the client?

• A. Match the client's identification band with the number on the blood unit
• B. Confirm the provider's prescription matches the number on the blood component
• C. Ask the client to state their blood type and confirm the date of their last blood donation
• D. Ensure that the client's identification band matches the number on the blood unit

Correct answer: D

Rationale: Ensuring that the client's identification band matches the number on the blood unit is crucial for correct identification. This action helps prevent errors by confirming that the blood product is indeed intended for the specific client. Matching the client's blood type with type and cross-match specimens (Choice A) is important for compatibility but does not directly verify the client's identity. Confirming the provider's prescription (Choice B) is relevant but does not ensure the correct identification of the client. Asking the client to state their blood type and confirm the date of their last blood donation (Choice C) relies on the client's memory and verbal confirmation, which may not be accurate or reliable for identification purposes.

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