Nursing Elites

1. A client who has been prescribed multiple antihypertensive medications experiences syncope and has a blood pressure of 70/40. What is the rationale for the nurse to hold the next scheduled antihypertensive dose?

• A. Increased urinary clearance of the medications has produced diuresis, lowering the blood pressure.
• B. The antagonistic interaction of the medications has reduced their effectiveness.
• C. The synergistic effect of the medications has resulted in drug toxicity, causing hypotension.
• D. The additive effect of the medications has lowered the blood pressure too much.

Correct answer: D

Rationale: The additive effect of multiple antihypertensive medications can cause hypotension, leading to dangerously low blood pressure. In this scenario, the client experiencing syncope with a blood pressure of 70/40 indicates severe hypotension, likely due to the combined action of the antihypertensive medications. Holding the next scheduled dose is essential to prevent further lowering of blood pressure and potential complications. Choices A, B, and C provide inaccurate explanations and do not align with the client's presentation and the need to manage hypotension caused by the additive effect of the medications.

2. The nurse is providing care for a client with advanced liver disease who is experiencing ascites. Which intervention should the nurse implement to help manage the client's fluid volume?

• A. Increase the client's sodium intake
• B. Encourage the client to drink more fluids
• C. Place the client in a supine position
• D. Administer a diuretic as prescribed

Correct answer: D

Rationale: Administering a diuretic as prescribed is the most appropriate intervention to manage fluid volume in a client with ascites due to advanced liver disease. Diuretics help reduce fluid accumulation in the body, including the abdominal cavity where ascites occurs. Increasing sodium intake would worsen fluid retention, and encouraging more fluid intake can exacerbate ascites. Placing the client in a supine position does not directly address the fluid volume issue associated with ascites.

3. When caring for a client with acute respiratory distress syndrome (ARDS), why does the nurse elevate the head of the bed 30 degrees?

• A. To reduce abdominal pressure on the diaphragm
• B. To promote oxygenation by improving lung expansion
• C. To encourage use of accessory muscles for breathing
• D. To drain secretions and prevent aspiration

Correct answer: D

Rationale: Elevating the head of the bed in a client with acute respiratory distress syndrome (ARDS) is essential to drain secretions and prevent aspiration. This position helps facilitate the removal of secretions from the airways, reducing the risk of aspiration pneumonia. Choices A, B, and C are incorrect as the primary reason for elevating the head of the bed in ARDS is to assist with secretion drainage and prevent complications associated with aspiration.

4. Which meal option should the nurse recommend for a client with renal disease who is following a low-protein diet?

• A. Grilled chicken with steamed vegetables
• B. Tofu stir-fry with rice
• C. Pasta with marinara sauce
• D. Baked salmon with quinoa

Correct answer: C

Rationale: The correct answer is C: Pasta with marinara sauce. Clients with renal disease following a low-protein diet should opt for lower-protein options. Pasta with marinara sauce is a suitable choice as it is lower in protein compared to grilled chicken, tofu, or salmon. Grilled chicken, tofu, and salmon are higher in protein content and are not ideal for individuals following a low-protein diet for renal disease as they may strain the kidneys.

5. A client with Type 1 diabetes reports feeling shaky and lightheaded. The nurse checks the client's blood glucose level and it is 60 mg/dL. What action should the nurse take first?

• A. Give the client a glucagon injection
• B. Encourage the client to eat a high-protein snack
• C. Recheck the blood glucose level in 15 minutes
• D. Administer 15 grams of a fast-acting carbohydrate

Correct answer: D

Rationale: The correct answer is D: Administer 15 grams of a fast-acting carbohydrate. The first step in treating hypoglycemia is to quickly raise the client's blood sugar level. Fast-acting carbohydrates like glucose tablets or juice are essential for this purpose. Giving a glucagon injection is typically reserved for severe hypoglycemia when the client is unable to take anything by mouth. Encouraging the client to eat a high-protein snack is not appropriate for immediate treatment of hypoglycemia. Rechecking the blood glucose level in 15 minutes is important after administering the fast-acting carbohydrate to ensure that the blood sugar has returned to a safe level.

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