Nursing Elites

1. What is the most important assessment for a patient with respiratory distress?

• A. Monitor oxygen saturation
• B. Check for abnormal breath sounds
• C. Check for pitting edema
• D. Perform a neurological exam

Correct answer: A

Rationale: Monitoring oxygen saturation is crucial in assessing a patient with respiratory distress because it helps determine if the patient is receiving adequate oxygen. Oxygen saturation levels provide immediate feedback on the efficiency of oxygen delivery to the tissues. Checking for abnormal breath sounds (Choice B) is relevant in respiratory assessments, but it is secondary to assessing oxygen saturation. Pitting edema (Choice C) and performing a neurological exam (Choice D) are not directly related to assessing respiratory distress and are not the primary focus when managing a patient with breathing difficulties.

2. A nurse is caring for a client who has generalized petechiae and ecchymoses. The nurse should expect a prescription for which of the following laboratory tests?

• A. Platelet count
• B. Potassium level
• C. Creatinine clearance
• D. Prealbumin

Correct answer: A

Rationale: The correct answer is A: Platelet count. Platelet count helps assess clotting abnormalities that could cause petechiae and ecchymoses. Petechiae and ecchymoses are often associated with bleeding disorders, so it is crucial to evaluate the platelet count to determine if there is a deficiency in platelets. Choices B, C, and D are incorrect because potassium level, creatinine clearance, and prealbumin do not directly relate to assessing clotting abnormalities associated with petechiae and ecchymoses.

3. A nurse is teaching a client who has heart failure about managing fluid intake. Which of the following instructions should the nurse include?

• A. Drink 2 liters of water per day.
• B. You should restrict your fluid intake to 1 liter per day.
• C. You can drink as much fluid as you want throughout the day.
• D. Limit your fluid intake to 3 liters per day.

Correct answer: B

Rationale: The correct answer is B: "You should restrict your fluid intake to 1 liter per day." Clients with heart failure should limit their fluid intake to prevent fluid overload, which can worsen their condition. Choice A is incorrect because 2 liters of water per day may be excessive for someone with heart failure. Choice C is incorrect as unlimited fluid intake is not suitable for individuals with heart failure. Choice D is also incorrect as 3 liters per day may be too much fluid for a client with heart failure.

4. A client reports that the medication appears different than what they take at home. Which of the following responses should the nurse take?

• A. Did the healthcare provider discuss with you that there was a change in this medication?
• B. I recommend that you take this medication as prescribed.
• C. Do you know why this medication is being prescribed to you?
• D. I will call the pharmacist now to check on this medication.

Correct answer: D

Rationale: Contacting the pharmacist is the most appropriate action to ensure the correct medication is being administered. This response addresses the client's concern directly and prioritizes patient safety. The other options do not directly address the issue of the medication discrepancy. Option A focuses on the healthcare provider's discussion, not the medication itself. Option B assumes that the current medication is correct without verification. Option C addresses the reason for the prescription but does not verify the medication's correctness.

5. A nurse is reviewing the medical record of a client who has a history of myocardial infarction. Which of the following findings should the nurse report to the provider?

• A. Blood pressure 140/90 mm Hg
• B. Heart rate of 88/min
• C. LDL cholesterol 110 mg/dL
• D. Respiratory rate of 16/min

Correct answer: D

Rationale: In a client with a history of myocardial infarction, a respiratory rate of 16/min should be reported to the provider. Changes in respiratory rate can indicate cardiac or pulmonary issues that need further evaluation. The other vital signs provided (blood pressure, heart rate, and LDL cholesterol level) are within normal limits and do not directly relate to potential complications following a myocardial infarction.

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