Nursing Elites

1. The nurse is caring for clients on a cardiac floor. Which client should the nurse assess first?

• A. The client with three (3) unifocal PVCs in a minute
• B. The client diagnosed with coronary artery disease who wants to ambulate
• C. The client diagnosed with mitral valve prolapse with an audible S3
• D. The client diagnosed with pericarditis who is in normal sinus rhythm

Correct answer: C

Rationale: The correct answer is C because an audible S3 in a client with mitral valve prolapse could indicate heart failure and requires immediate assessment. Choice A is not as urgent as an audible S3 in mitral valve prolapse. Choice B, a client with coronary artery disease wanting to ambulate, does not present an immediate concern compared to a potential heart failure indicated by an audible S3. Choice D, a client with pericarditis in normal sinus rhythm, is stable and does not require immediate attention when compared to a potential heart failure situation signified by an audible S3 in mitral valve prolapse.

2. What is the best way to manage a patient's intake of dietary fiber?

• A. Increase intake gradually
• B. Increase intake suddenly
• C. Decrease intake abruptly
• D. Maintain a high intake

Correct answer: A

Rationale: The correct way to manage a patient's intake of dietary fiber is to increase it gradually. This approach helps prevent gastrointestinal discomfort that can occur when fiber intake is suddenly increased. Choice B is incorrect because sudden increases in fiber intake can lead to bloating, gas, and other digestive issues. Choice C is incorrect as decreasing fiber intake abruptly can disrupt bowel regularity and cause constipation. Choice D is incorrect because maintaining a high intake of fiber without considering the patient's current levels can also cause digestive problems.

3. Which potential complication should the nurse assess for in the client with infective endocarditis who has embolization of vegetative lesions from the mitral valve?

• A. Pulmonary embolism
• B. Decreased urine output
• C. Hemoptysis
• D. Deep vein thrombosis

Correct answer: B

Rationale: The correct answer is B: Decreased urine output. When vegetative lesions from the mitral valve embolize, they can block blood flow to the kidneys, leading to renal infarction. This can result in decreased urine output. Choices A, C, and D are incorrect. Pulmonary embolism involves a blockage of an artery in the lungs, not directly related to embolization from the mitral valve. Hemoptysis is the coughing up of blood from the respiratory tract, which is not a direct consequence of embolization from the mitral valve. Deep vein thrombosis is the formation of a blood clot in a deep vein, unrelated to embolization from the mitral valve.

4. Which of the following is a potential side effect associated with the use of nonsteroidal anti-inflammatory drugs?

• A. Stomach irritation and bleeding
• B. Stomatitis and esophagitis
• C. Impaired folate absorption
• D. Increased potassium excretion

Correct answer: A

Rationale: The correct answer is A: Stomach irritation and bleeding. Nonsteroidal anti-inflammatory drugs (NSAIDs) can cause stomach irritation and bleeding due to their effects on gastric mucosa. Stomatitis and esophagitis (Choice B) are not typically associated with NSAID use. While NSAIDs may affect renal function, leading to fluid retention and edema, they do not directly cause increased potassium excretion (Choice D). Impaired folate absorption (Choice C) is not a common side effect of NSAIDs.

5. A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client’s fluid status?

• A. Measuring and recording fluid intake and output
• B. Weighing the client daily at the same time each day
• C. Assessing the client’s vital signs every 4 hours
• D. Checking the client’s lungs for crackles during every shift

Correct answer: B

Rationale: Weighing the client daily at the same time each day is the most accurate method for monitoring fluid balance. Changes in body weight can reflect fluid retention or loss. Measuring and recording fluid intake and output (Choice A) is important but may not provide immediate changes in fluid status. Assessing vital signs (Choice C) can offer some information but may not be as specific to fluid status as daily weighing. Checking the client's lungs for crackles (Choice D) is more related to assessing respiratory status rather than direct fluid monitoring.

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