Nursing Elites

1. A nurse is caring for a patient with heart failure who has developed pulmonary edema. What is the nurse's priority action?

• A. Administer a diuretic as prescribed.
• B. Place the patient in a high Fowler's position.
• C. Administer oxygen via nasal cannula.
• D. Monitor the patient's lung sounds every 2 hours.

Correct answer: B

Rationale: The correct answer is to place the patient in a high Fowler's position. This position helps improve lung expansion and oxygenation in cases of pulmonary edema by reducing venous return to the heart and enhancing respiratory mechanics. Administering a diuretic (Choice A) can be important but is not the priority over positioning in this situation. Administering oxygen (Choice C) is essential, but the priority action for improving oxygenation is the positioning of the patient. Monitoring lung sounds (Choice D) is crucial for ongoing assessment but is not the priority action when the patient is in distress with pulmonary edema.

2. A nurse is preparing to administer enoxaparin to a client. Which of the following actions should the nurse plan to take?

• A. Aspirate for a blood return before depressing the plunger
• B. Insert the needle at a 45-degree angle
• C. Administer the medication 2.54 cm (1 in) from the umbilicus
• D. The nurse should not expel the air bubble in the prefilled syringe

Correct answer: D

Rationale: The correct action when administering enoxaparin is not to expel the air bubble in the prefilled syringe. Expelling the air bubble may lead to the loss of medication and result in an incomplete dose. Aspirating for a blood return (Choice A) is not necessary for subcutaneous injections like enoxaparin. Inserting the needle at a 45-degree angle (Choice B) is not specific to administering enoxaparin. Administering the medication 2.54 cm (1 in) from the umbilicus (Choice C) is not a standard guideline for enoxaparin administration.

3. Which action by the nurse demonstrates effective infection control measures?

• A. Perform hand hygiene before and after patient contact.
• B. Wear gloves when administering medications.
• C. Dispose of used equipment in designated containers.
• D. Wear a mask when interacting with the patient.

Correct answer: A

Rationale: The correct answer is A: Perform hand hygiene before and after patient contact. Effective hand hygiene is a fundamental infection control measure that helps prevent the spread of pathogens. Wearing gloves when administering medications (choice B) is important for protecting both the patient and the nurse but is not a direct demonstration of infection control. Disposing of used equipment in designated containers (choice C) is more related to proper waste management than infection control. Wearing a mask when interacting with the patient (choice D) is essential in certain situations, but hand hygiene is a more universal and critical practice for infection control.

4. A patient is being treated for dehydration. Which lab result would support the diagnosis?

• A. Elevated hemoglobin
• B. Low sodium level
• C. High white blood cell count
• D. Elevated BUN

Correct answer: D

Rationale: Elevated BUN levels are a characteristic finding in dehydration due to reduced kidney perfusion and increased reabsorption of urea. Hemoglobin levels might be elevated in conditions like polycythemia vera, not directly related to dehydration. A low sodium level could be seen in conditions like hyponatremia. A high white blood cell count is more indicative of infection or inflammation rather than dehydration.

5. A healthcare professional is assessing a patient's fluid balance. What is the most reliable indicator of fluid status?

• A. Monitor the patient's vital signs.
• B. Check the patient's weight daily.
• C. Measure the patient's intake and output.
• D. Monitor the patient's urine color.

Correct answer: B

Rationale: Checking the patient's weight daily is the most reliable indicator of fluid status because weight changes can directly reflect fluid retention or loss. Monitoring vital signs (Choice A) can provide some information but is not as specific as weight changes. Measuring intake and output (Choice C) is crucial but may not always accurately reflect fluid balance. Monitoring urine color (Choice D) can give some insights into hydration levels, but it is not as reliable as daily weight checks for assessing overall fluid status.

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