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. When caring for a client's tracheostomy at home, which instruction should the nurse include in the teaching?

• A. Clean with alcohol
• B. Cover the tracheostomy when outside
• C. Replace the tube weekly
• D. Use tap water to clean

Correct answer: B

Rationale: Covering the tracheostomy when outside is crucial as it helps prevent dust and other irritants from entering the airway, reducing the risk of complications. Cleaning with alcohol (choice A) can be too harsh for the skin around the tracheostomy site. While replacing the tube weekly (choice C) is important, it is typically done by healthcare providers. Using tap water to clean (choice D) is not recommended as it may introduce contaminants to the tracheostomy site.

3. A patient with heart failure has gained 5 pounds in the last 3 days. What is the nurse's priority intervention?

• A. Restrict the patient's fluid intake.
• B. Monitor the patient's daily weight.
• C. Administer diuretics as prescribed.
• D. Increase the patient's salt intake to promote fluid balance.

Correct answer: B

Rationale: The correct answer is to monitor the patient's daily weight. In heart failure, sudden weight gain indicates fluid retention, which can worsen the condition. Monitoring daily weight helps in early detection of fluid accumulation, allowing timely intervention. Restricting fluid intake (choice A) may be necessary but is not the priority at this point. Administering diuretics (choice C) should be done based on healthcare provider orders, not the nurse's independent decision. Increasing salt intake (choice D) is contraindicated in heart failure as it can exacerbate fluid retention.

4. Which of the following is an example of professional negligence?

• A. Following facility guidelines at all times
• B. Using equipment in a knowledgeable manner
• C. Communicating effectively with clients
• D. Documenting client interactions accurately

Correct answer: A

Rationale: Professional negligence involves failing to meet the standard of care expected in a particular profession, which can lead to harm. In this case, not following facility guidelines can result in lapses in safety or quality of care, potentially causing harm to clients. Choices B, C, and D all represent essential aspects of professional conduct and do not directly relate to negligence.

5. What is an expected finding during the assessment of a client transitioning into a new role?

• A. The client's ability to express feelings of guilt
• B. Presence of suicidal or homicidal ideation
• C. Changes in coping skills over the past few weeks
• D. Client's involvement in community activities

Correct answer: B

Rationale: During a client's transition into a new role, the presence of suicidal or homicidal ideation should be assessed due to the increased risk associated with significant life changes. This finding could indicate a need for immediate intervention. While assessing the client's ability to express feelings of guilt is important, it may not be the most critical aspect during this specific assessment. Changes in coping skills over time are relevant but might not be the primary focus during a role transition assessment. The client's involvement in community activities, although beneficial for social support, is not directly related to the immediate concerns of assessing a client transitioning into a new role.

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