Nursing Elites

1. What is the best method to assess for fluid overload in patients with heart failure?

• A. Monitor daily weight
• B. Check for jugular vein distention
• C. Check for pitting edema
• D. Check for fluid retention

Correct answer: A

Rationale: The correct answer is A: Monitor daily weight. Daily weight monitoring is the most accurate method to assess fluid overload in patients with heart failure. Changes in weight can indicate fluid retention before visible signs like jugular vein distention or pitting edema appear. Checking for jugular vein distention (choice B) is helpful but may not be as sensitive as daily weight monitoring. Pitting edema (choice C) and fluid retention (choice D) are signs of fluid overload, but daily weight monitoring is a more proactive approach to detect changes early.

2. A nurse is preparing to perform a bladder scan for a client who has overflow incontinence. Which of the following actions should the nurse take?

• A. Place the client in a supine position.
• B. Obtain a prescription for insertion of an indwelling catheter.
• C. Cleanse the client's abdomen with an antiseptic solution.
• D. Prepare the client for urinary catheterization.

Correct answer: D

Rationale: The correct answer is to prepare the client for urinary catheterization. Overflow incontinence may indicate bladder distention, where a bladder scan helps assess the need for catheterization. Placing the client in a supine position (Choice A) is not directly related to the procedure. Obtaining a prescription for an indwelling catheter (Choice B) is not necessary before performing a bladder scan. Cleansing the client's abdomen with an antiseptic solution (Choice C) is not specific to preparing for a bladder scan in this situation.

3. Four clients present to the emergency department. The nurse should plan to see which of the following clients first?

• A. A 6-year-old client with a dislocated left shoulder
• B. A 26-year-old client with sickle cell disease and severe joint pain
• C. A 76-year-old client who is confused, febrile, and has foul-smelling urine
• D. A 50-year-old client with slurred speech, disorientation, and headache

Correct answer: D

Rationale: The correct answer is D. A client presenting with symptoms of a stroke, such as slurred speech, disorientation, and headache, requires immediate attention due to the possibility of a neurological emergency. Choices A, B, and C, although concerning, do not present with symptoms as urgent as those of a potential stroke. Dislocated shoulder, sickle cell disease with joint pain, and confusion with febrile illness can be addressed after ensuring the client with stroke-like symptoms receives prompt evaluation and intervention.

4. What is the initial nursing action for a patient presenting with chest pain?

• A. Administer aspirin
• B. Reposition the patient
• C. Provide pain relief
• D. Prepare for surgery

Correct answer: A

Rationale: The correct initial nursing action for a patient presenting with chest pain is to administer aspirin. Aspirin helps reduce the risk of further clot formation in patients experiencing chest pain, as it has antiplatelet effects. Repositioning the patient, providing pain relief, or preparing for surgery are not the first-line interventions for chest pain. Repositioning the patient may be necessary to ensure comfort and safety, pain relief can be provided after further assessment and diagnostic tests, and preparing for surgery would only be considered after a thorough evaluation and confirmation of the need for surgical intervention.

5. A nurse is caring for a client who is at 38 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?

• A. Fetal heart rate of 110/min
• B. 1+ pitting edema
• C. Blood pressure 138/80 mm Hg
• D. Urine output of 20 mL/hr

Correct answer: D

Rationale: The correct answer is D. Urine output less than 30 mL/hr indicates decreased kidney perfusion, which is a serious complication of preeclampsia. Reporting this finding is crucial for prompt intervention. Choices A, B, and C are not the priority as fetal heart rate of 110/min, 1+ pitting edema, and blood pressure of 138/80 mm Hg are within normal limits for a client with preeclampsia at 38 weeks of gestation.

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