Nursing Elites

1. A client with a diagnosis of hyperthyroidism is being discharged. Which instruction should the nurse include in the discharge teaching?

• A. Avoid foods high in iodine.
• B. Take your medication with meals.
• C. Monitor your weight daily.
• D. Decrease your daily fluid intake.

Correct answer: A

Rationale: The correct answer is A: 'Avoid foods high in iodine.' Clients with hyperthyroidism should avoid foods high in iodine to prevent exacerbation of their condition. Iodine is an essential component in thyroid hormone production, and excessive iodine intake can worsen hyperthyroidism symptoms. Taking medication with meals (B) can interfere with the absorption of certain thyroid medications. Monitoring weight daily (C) is more relevant for conditions that may lead to weight changes like hypothyroidism. Decreasing fluid intake (D) is not a standard recommendation for hyperthyroidism unless specifically indicated by the healthcare provider.

2. An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP?

• A. Position the client on the right side of the bed in reverse Trendelenburg.
• B. Fill the enema container with 1000 ml of warm water and 5 ml of castile soap.
• C. Reposition the client in the Sims' position.
• D. Raise the side rails on both sides of the bed and elevate the bed to waist level.

Correct answer: C

Rationale: The correct position for administering a soap suds enema is the Sims' position, not the left lateral position. The Sims' position allows the enema solution to follow the anatomical course of the intestines and provides the best overall results. By repositioning the client in the Sims' position, the weight is distributed to the anterior ilium, facilitating the enema administration process.

3. A client is diagnosed with primary hypertension. Which assessment finding is most commonly associated with this diagnosis?

• A. Headache
• B. Dizziness
• C. Fatigue
• D. Edema

Correct answer: A

Rationale: Headache (A) is the most commonly associated symptom with primary hypertension due to increased pressure in the blood vessels, leading to headaches. While dizziness (B), fatigue (C), and edema (D) may also occur in hypertension, headache is the most frequently reported symptom among individuals with primary hypertension.

4. A CVA (stroke) patient goes into respiratory distress and is placed on a ventilator. The client’s daughter arrives with a durable power of attorney and a living will that indicates there should be no extraordinary life-saving measures. What action should the nurse take?

• A. Refer to the risk manager
• B. Notify the healthcare provider
• C. Discontinue the ventilator
• D. Review the medical record

Correct answer: B

Rationale: In this situation, the nurse should notify the healthcare provider. The healthcare provider needs to be informed to review the legal documents provided by the patient's daughter, such as the durable power of attorney and living will, which specify the patient's wishes regarding life-saving measures. The healthcare provider will be responsible for making the appropriate decision based on the legal documents and the patient's current condition. Referring to the risk manager (choice A) is not necessary as the issue at hand pertains to the patient's medical care. Discontinuing the ventilator (choice C) without healthcare provider input could go against the patient's wishes and legal documents. Reviewing the medical record (choice D) may not provide immediate guidance on the current situation and the patient's preferences regarding life-saving measures.

5. After surgery, a client who had a colostomy says 'I know the doctor did not really do a colostomy'. The nurse understands that the client is in an early stage of adjustment to the diagnosis or surgery. What nursing action is indicated at this time?

• A. Agree with the client until they are ready to accept the colostomy.
• B. Say 'It must be difficult to have this kind of surgery'.
• C. Force the client to look at their colostomy.
• D. Ask the surgeon to explain the surgery to the client.

Correct answer: B

Rationale: Acknowledging the client's feelings with empathy is essential in the early stage of adjustment to a colostomy surgery. By saying 'It must be difficult to have this kind of surgery,' the nurse validates the client's emotions and opens up a channel for further communication. Choice A is incorrect because agreeing with the client's denial is not therapeutic and may hinder acceptance. Choice C is inappropriate as it disregards the client's emotional state and autonomy. Choice D involves the surgeon and is not the nurse's role in addressing the client's emotional needs.

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