Nursing Elites

1. The client with a history of left-sided heart failure is exhibiting increasing shortness of breath and frothy sputum. What is the priority nursing action?

• A. Administer oxygen
• B. Encourage coughing and deep breathing
• C. Place the client in a supine position
• D. Notify the healthcare provider immediately

Correct answer: A

Rationale: Shortness of breath and frothy sputum are indicative of pulmonary edema, a serious condition that requires immediate intervention to improve oxygenation. Administering oxygen is the priority action to support the client's respiratory function and prevent further deterioration. Oxygen therapy helps increase the oxygen levels in the blood, alleviate respiratory distress, and support vital organ function. Prompt intervention with oxygen can help stabilize the client while further assessments and treatments are initiated. Encouraging coughing and deep breathing may worsen the client's condition by increasing respiratory effort. Placing the client in a supine position can further compromise breathing in a client with pulmonary edema. Notifying the healthcare provider is important but not the priority when the client's respiratory status is deteriorating.

2. A client is diagnosed with thrombophlebitis. The nurse should tell the client that which prescription is indicated?

• A. Bed rest, with bathroom privileges only
• B. Bed rest, keeping the affected extremity flat
• C. Bed rest, with elevation of the affected extremity
• D. Bed rest, with the affected extremity in a dependent position

Correct answer: C

Rationale: The correct answer is C: Bed rest, with elevation of the affected extremity. Elevating the affected extremity is crucial in managing thrombophlebitis as it helps reduce swelling and promotes venous return. By elevating the affected extremity, the gravitational force assists in venous blood flow back to the heart, thereby reducing the risk of complications associated with thrombophlebitis. Choices A, B, and D are incorrect because they do not address the need for elevation, which is specifically beneficial in the management of thrombophlebitis.

3. A client with a diagnosis of myocardial infarction has a new activity prescription allowing the client to have bathroom privileges. As the client stands and begins to walk, the client begins to complain of chest pain. The nurse should take which action?

• A. Assist the client to get back into bed.
• B. Report the chest pain episode to the healthcare provider.
• C. Tell the client to stand still and take the client's blood pressure.
• D. Give a nitroglycerin (Nitrostat) tablet and assist the client to the bathroom.

Correct answer: A

Rationale: In a client with myocardial infarction experiencing chest pain during activity, the priority action is to stop the activity immediately to reduce the heart's workload and oxygen demand. Assisting the client back to bed helps in reducing stress on the heart and can prevent worsening of the condition. Reporting the chest pain episode to the healthcare provider is important but should not delay taking immediate action to alleviate symptoms. Taking the client's blood pressure and administering nitroglycerin are secondary actions after ensuring the client's safety and comfort. Therefore, the correct action is to assist the client back into bed.

4. A client who has been taking prednisone is being assessed by a nurse. Which of the following findings should the nurse report to the provider?

• A. Weight gain
• B. Hyperglycemia
• C. Dry mouth
• D. Increased appetite

Correct answer: B

Rationale: Hyperglycemia is a significant finding in a client taking prednisone as it indicates the medication's impact on glucose metabolism. Prednisone can lead to increased blood sugar levels, which can be detrimental, especially in clients with diabetes or predisposition to hyperglycemia. Reporting hyperglycemia promptly to the healthcare provider is crucial for further evaluation and management to prevent complications. Choices A, C, and D are common side effects of prednisone but are not as concerning as hyperglycemia, which requires immediate attention to avoid potential adverse effects.

5. The client with a diagnosis of heart failure is receiving furosemide (Lasix). Which laboratory value is most important for the nurse to monitor?

• A. Blood glucose
• B. Serum sodium
• C. Serum potassium
• D. Blood urea nitrogen (BUN)

Correct answer: C

Rationale: The correct answer is C: Serum potassium. When a client is receiving furosemide, a loop diuretic, it can lead to potassium loss. Monitoring the serum potassium levels is crucial to prevent life-threatening complications such as cardiac arrhythmias. Blood glucose (Choice A) is not directly impacted by furosemide. Serum sodium (Choice B) may be affected, but monitoring potassium is more critical due to the risk of arrhythmias. Blood urea nitrogen (BUN) (Choice D) is important for assessing kidney function but is not the most crucial value to monitor in a client taking furosemide.

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