Nursing Elites

1. The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment would best evaluate the effectiveness of the therapies?

• A. Observe for distended neck veins.
• B. Auscultate for crackles in the lungs.
• C. Palpate for heaves or thrills over the heart.
• D. Review hemoglobin and hematocrit values.

Correct answer: A

Rationale: To evaluate the effectiveness of therapies for cor pulmonale and right-sided heart failure, observing for distended neck veins would be the most appropriate assessment. Cor pulmonale is characterized by right ventricular failure due to pulmonary hypertension, leading to clinical manifestations such as peripheral edema, jugular venous distention, and right upper-quadrant abdominal tenderness. These signs indicate increased central venous pressure and right heart strain, which can be assessed by observing for distended neck veins. Auscultating for crackles in the lungs is more indicative of left-sided heart failure rather than right-sided heart failure. Heaves or thrills over the heart are not typically associated with cor pulmonale. Reviewing hemoglobin and hematocrit values may show elevations due to chronic hypoxemia and polycythemia in cor pulmonale, but these values alone do not directly evaluate the immediate effectiveness of the prescribed therapies on the patient's condition.

2. While receiving normal saline infusions to treat a GI bleed, the nurse notes that the patient's lower legs have become edematous and auscultates crackles in the lungs. What should the nurse do first?

• A. Stop the saline infusion immediately
• B. Notify the physician
• C. Elevate the patient's legs
• D. Continue the infusion, as these findings are normal

Correct answer: A

Rationale: The correct answer is to stop the saline infusion immediately. The patient is showing signs of fluid volume overload due to rapid fluid replacement, indicated by lower leg edema and lung crackles. Continuing the infusion could worsen the overload and potentially lead to complications. Notifying the physician is important but should come after stopping the infusion to address the immediate issue. Elevating the patient's legs may help with edema but is not the priority in this situation. Continuing the infusion when the patient is already showing signs of fluid overload is contraindicated and can be harmful.

3. What nursing intervention demonstrates that the nurse understands the priority nursing diagnosis when caring for oral cancer patients with extensive tumor involvement and/or a high amount of secretions?

• A. The nurse uses a pen pad to communicate with the patient
• B. The nurse provides oral care every 2 hours
• C. The nurse listens for bowel sounds every 4 hours
• D. The nurse suctions as needed and elevates the head of the bed

Correct answer: D

Rationale: The correct answer is to suction as needed and elevate the head of the bed. This intervention is crucial for managing Ineffective Airway Clearance, which is the priority nursing diagnosis in oral cancer patients with extensive tumor involvement and/or a high amount of secretions. Suctioning helps clear secretions that may obstruct the airway, while elevating the head of the bed promotes optimal respiratory function. Providing oral care every 2 hours may be important for overall oral health but is not directly related to addressing the priority diagnosis. Listening for bowel sounds every 4 hours is more relevant to gastrointestinal assessment and not specific to managing airway clearance issues in oral cancer patients.

4. A 25-year-old male client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication:

• A. Should be taken in the morning
• B. May increase the client's energy level
• C. Does not need to be stored in a dark container
• D. May increase the client's heart rate

Correct answer: A

Rationale: The correct answer is that levothyroxine (Synthroid) should be taken in the morning. Taking it in the morning can help prevent interference with the client's sleeping pattern, as one of the side effects of levothyroxine is insomnia. Choice B is incorrect because levothyroxine is actually used to treat hypothyroidism and can help increase energy levels. Choice C is incorrect as there is no specific requirement for levothyroxine to be stored in a dark container. Choice D is incorrect because levothyroxine is more likely to increase heart rate rather than decrease it.

5. A client had a closed reduction of a fractured right wrist followed by the application of a fiberglass cast 12 hours ago. Which finding requires immediate attention?

• A. Capillary refill of fingers on right hand is 3 seconds
• B. Skin warm to touch and normally colored
• C. Client reports prickling sensation in the right hand
• D. Slight swelling of fingers of right hand

Correct answer: C

Rationale: A prickling sensation in the right hand is indicative of compartment syndrome, a serious condition that can lead to tissue damage and impaired circulation. Immediate attention is required to prevent complications. Capillary refill of 3 seconds, warm and normally colored skin, and slight swelling of fingers are expected findings after a closed reduction and casting. These findings do not typically indicate a critical issue and can be managed with routine monitoring.

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