Nursing Elites

1. What is a primary symptom of left-sided heart failure?

• A. Shortness of breath
• B. Edema
• C. Rapid heartbeat
• D. Confusion

Correct answer: A

Rationale: Shortness of breath is a primary symptom of left-sided heart failure. In this condition, the heart's inability to pump effectively leads to fluid backing up into the lungs, causing difficulty breathing. Edema (swelling), rapid heartbeat, and confusion are more commonly associated with other conditions or right-sided heart failure. Edema is often seen in right-sided heart failure due to fluid accumulation in the body, rapid heartbeat can be a general sign of heart issues, and confusion is more related to decreased brain perfusion in severe heart failure cases.

2. A nurse is reinforcing teaching with a client who has dumping syndrome about measures to reduce manifestations. Which of the following instructions should the nurse include in the teaching?

• A. Drink plenty of fluids after meals
• B. Increase sugar intake
• C. Eat smaller, more frequent meals
• D. Avoid foods high in sugar content

Correct answer: D

Rationale: The correct instruction the nurse should include in teaching a client with dumping syndrome is to 'Avoid foods high in sugar content.' Dumping syndrome occurs when high-sugar foods move too quickly into the small intestine, leading to symptoms like abdominal cramps, diarrhea, and bloating. By avoiding foods high in sugar content, the client can reduce these symptoms. Choices A, B, and C are incorrect. Drinking plenty of fluids after meals may exacerbate symptoms by speeding up the movement of food through the digestive system. Increasing sugar intake would worsen dumping syndrome symptoms. While eating smaller, more frequent meals is a good strategy, the key emphasis should be on avoiding high-sugar foods.

3. What is the proper technique for measuring blood pressure manually?

• A. Use a stethoscope to listen for the Korotkoff sounds
• B. Ensure the patient is seated with the arm supported
• C. Use a manual sphygmomanometer
• D. Deflate the cuff slowly while listening to the heartbeat

Correct answer: A

Rationale: The correct technique for measuring blood pressure manually involves using a stethoscope to listen for the Korotkoff sounds. Choice B, ensuring the patient is seated with the arm supported, is important but not the specific technique for measuring blood pressure. Choice C, using a manual sphygmomanometer, is a necessary tool but not the technique itself. Choice D, deflating the cuff slowly while listening to the heartbeat, is not the correct technique as the deflation should be done while listening for the Korotkoff sounds to determine the systolic and diastolic blood pressure readings.

4. A client needs a 24-hour urine collection initiated. Which of the following client statements indicates an understanding of the procedure?

• A. I had a bowel movement, but I was able to save the urine.
• B. I have a specimen in the bathroom from about 30 minutes ago.
• C. I flushed what I urinated at 7 am and have saved the rest since.
• D. I drink a lot, so I will fill up the bottle and complete the test quickly.

Correct answer: C

Rationale: Choice C is correct because it demonstrates the client's understanding of the procedure, which involves discarding the first urine of the day at the specified time and then saving all subsequent urine for the next 24 hours. Choices A, B, and D do not reflect an understanding of the correct procedure. Choice A is incorrect because bowel movements are not part of a 24-hour urine collection. Choice B is incorrect as it does not specify discarding the first urine. Choice D is incorrect as it mentions filling up the bottle quickly, which is not the correct way to collect a 24-hour urine sample.

5. How do you assess for dehydration in a pediatric patient?

• A. Check for dry mouth and decreased urine output
• B. Monitor skin turgor and capillary refill
• C. Assess for lethargy and irritability
• D. Monitor blood pressure and heart rate

Correct answer: A

Rationale: Correct! When assessing for dehydration in a pediatric patient, checking for dry mouth and decreased urine output are crucial indicators. Dry mouth indicates reduced fluid intake or dehydration, while decreased urine output suggests decreased renal perfusion secondary to dehydration. Skin turgor and capillary refill are more indicative of perfusion status rather than dehydration specifically. Lethargy and irritability can be present in dehydrated patients but are more general signs of illness. Monitoring blood pressure and heart rate are important in assessing dehydration severity but are not the initial signs used for assessment.

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