Nursing Elites

1. How should a healthcare professional assess a patient with potential pneumonia?

• A. Assess lung sounds and monitor oxygen saturation
• B. Monitor for fever and sputum production
• C. Auscultate heart sounds and check for cyanosis
• D. Monitor for chest pain and administer oxygen

Correct answer: A

Rationale: Correctly assessing a patient with potential pneumonia involves listening to lung sounds and monitoring oxygen saturation. Lung sounds can reveal abnormal breath sounds associated with pneumonia, such as crackles or diminished breath sounds. Oxygen saturation monitoring helps in detecting respiratory distress, a common complication of pneumonia. Monitoring for fever and sputum production (Choice B) is important but not as specific as assessing lung sounds and oxygen saturation. Auscultating heart sounds and checking for cyanosis (Choice C) are not primary assessments for pneumonia. Monitoring for chest pain and administering oxygen (Choice D) are relevant interventions but do not address the initial assessment of pneumonia.

2. A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field?

• A. Place the cap from the solution sterile side up on a clean surface.
• B. Open the outermost flap of the sterile kit away from the body.
• C. Place the sterile dressing within 1.25 cm (0.5 in) of the edge of the sterile field.
• D. Set up the sterile field 5 cm (2 in) above waist level.

Correct answer: A

Rationale: To maintain the sterility of the field, the nurse should place the cap from the solution sterile side up on a clean surface. This action helps prevent contamination. Choice B is incorrect because opening the outermost flap toward the body increases the risk of introducing contaminants onto the sterile field. Choice C is incorrect as the sterile dressing should be placed at least 2.5 cm (1 in) from the edge of the sterile field to prevent accidental contamination. Choice D is incorrect because setting up the sterile field above waist level could lead to inadvertent contact and compromise the field's sterility.

3. How should a healthcare professional assess a patient with suspected deep vein thrombosis (DVT)?

• A. Monitor for leg pain, swelling, and redness
• B. Check for calf tenderness and administer anticoagulants
• C. Check for discoloration and monitor oxygen saturation
• D. Check for numbness and provide thrombolytic therapy

Correct answer: A

Rationale: Correct Answer: The correct way to assess a patient with suspected deep vein thrombosis (DVT) is to monitor for leg pain, swelling, and redness. These are common clinical manifestations of DVT. Choice B is incorrect because administering anticoagulants should be based on a confirmed diagnosis, not just suspicion. Choice C is incorrect because discoloration and oxygen saturation are not primary indicators of DVT. Choice D is incorrect because numbness is not a typical symptom of DVT, and thrombolytic therapy is not the first-line treatment for suspected DVT.

4. A client who is to undergo an exercise stress test is being taught by a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should eat a large meal 2 hours before the test
• B. I should avoid drinking water before the test
• C. I should stop taking my blood pressure medication
• D. I should report any chest pain during the test

Correct answer: D

Rationale: The correct answer is D: 'I should report any chest pain during the test.' This statement indicates an understanding of the teaching because reporting chest pain during an exercise stress test is crucial as it may signify cardiac distress. Choices A, B, and C are incorrect. Eating a large meal 2 hours before the test is not recommended as it may affect the results. Avoiding drinking water before the test is also not advisable as staying hydrated is important. Stopping blood pressure medication without medical advice can be dangerous, especially before a stress test.

5. What are the primary differences between left-sided and right-sided heart failure?

• A. Left-sided: Pulmonary congestion; Right-sided: Systemic edema
• B. Right-sided: Pulmonary congestion; Left-sided: Systemic edema
• C. Left-sided: Systemic edema; Right-sided: Pulmonary congestion
• D. Right-sided: Pulmonary congestion; Left-sided: Heart failure

Correct answer: A

Rationale: The correct answer is A: "Left-sided: Pulmonary congestion; Right-sided: Systemic edema." Left-sided heart failure primarily affects the lungs, leading to pulmonary congestion, which manifests as symptoms like shortness of breath and cough. On the other hand, right-sided heart failure causes systemic congestion and edema, often presenting as swelling in the legs and abdomen due to fluid retention. Choice B is incorrect because it swaps the features of left-sided and right-sided heart failure. Choice C is incorrect as it also incorrectly switches the characteristics of the two types of heart failure. Choice D is incorrect because it inaccurately associates left-sided heart failure with pulmonary congestion and right-sided heart failure with heart failure itself, which is not a distinguishing feature.

Similar Questions