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 reviewing the medical record of a client who is at 30 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?

• A. Blood pressure 140/90 mm Hg
• B. 1+ pitting edema in the lower extremities
• C. Weight gain of 2.3 kg (5 lb) in 1 week
• D. Mild headache

Correct answer: C

Rationale: A weight gain of 2.3 kg (5 lb) in 1 week can indicate worsening preeclampsia due to fluid retention, which can lead to serious complications. This finding should be reported promptly to the provider for further assessment and intervention. Blood pressure of 140/90 mm Hg is high but may not be an immediate concern for a client with preeclampsia at 30 weeks. 1+ pitting edema in the lower extremities is common in pregnancy, especially in the third trimester, and may not be a significant finding in isolation. A mild headache can be a common symptom in pregnancy and may not be indicative of worsening preeclampsia unless accompanied by other concerning signs.

3. A nurse is caring for a client who is receiving morphine for pain management. Which of the following findings indicates the client is experiencing an adverse effect of the medication?

• A. Diaphoresis
• B. Hypotension
• C. Urinary retention
• D. Tachycardia

Correct answer: C

Rationale: Urinary retention is an adverse effect of morphine, as it can lead to the relaxation of the detrusor muscle and sphincter constriction in the bladder. Diaphoresis, hypotension, and tachycardia are common side effects of morphine due to its vasodilatory effects and impact on the autonomic nervous system. Diaphoresis is excessive sweating, which can be a normal response to pain or fever. Hypotension and tachycardia can occur due to morphine's vasodilatory effects and its impact on the cardiovascular system. Therefore, the presence of urinary retention would indicate the need for further assessment and intervention.

4. A nurse is caring for a client who has heart failure and a prescription for digoxin. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 60/min
• B. Respiratory rate of 16/min
• C. Sodium level of 138 mEq/L
• D. Weight gain of 1.5 kg (3.3 lb) in 24 hours

Correct answer: D

Rationale: The correct answer is D. A weight gain of 1.5 kg (3.3 lb) in 24 hours can indicate fluid retention and worsening heart failure in clients taking digoxin. This rapid weight gain could be due to fluid accumulation, a common sign of heart failure exacerbation. Reporting this finding to the provider is crucial for prompt intervention. Choices A, B, and C are within normal ranges and not directly indicative of worsening heart failure in this context, making them less urgent to report compared to the significant weight gain.

5. A nurse is caring for a client who has schizophrenia. Which of the following findings should the nurse expect?

• A. Decreased level of consciousness
• B. Inability to identify common objects
• C. Preoccupation with somatic disturbances
• D. Poor problem-solving ability

Correct answer: B

Rationale: The correct answer is B: Inability to identify common objects. Clients with schizophrenia often experience cognitive deficits, such as difficulty in identifying common objects. This can be attributed to impairments in perception and cognition. Choices A, C, and D are not typically associated with schizophrenia. Decreased level of consciousness is more indicative of conditions like head injuries or metabolic disturbances. Preoccupation with somatic disturbances is commonly seen in somatic symptom disorders, not schizophrenia. Poor problem-solving ability is a characteristic of conditions affecting executive functioning like dementia, rather than schizophrenia.

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