Nursing Elites

1. A client with hypertension is asking for lifestyle changes. What should the nurse recommend?

• A. Increase sodium intake to manage blood pressure
• B. Reduce caffeine and alcohol consumption
• C. Encourage the client to increase protein intake
• D. Increase intake of fruits and vegetables

Correct answer: B

Rationale: The correct answer is B: Reduce caffeine and alcohol consumption. This recommendation is crucial for managing hypertension as excessive caffeine and alcohol intake can elevate blood pressure. By reducing these stimulants, the client can help regulate their blood pressure levels. Choices A, C, and D are incorrect. Increasing sodium intake (Choice A) is contraindicated in hypertension as it can lead to fluid retention and worsen blood pressure. Encouraging increased protein intake (Choice C) and increasing intake of fruits and vegetables (Choice D) are generally healthy dietary suggestions but not specifically targeted at managing hypertension.

2. A nurse is collecting data from a client who has a newly applied cast to the right lower extremity. Which of the following findings should the nurse expect?

• A. Capillary refill of 1 second
• B. Capillary refill of 5 seconds
• C. Pitting edema
• D. Shortness of breath

Correct answer: B

Rationale: When assessing a client with a newly applied cast, the nurse should expect a capillary refill of approximately 2 seconds, as this indicates adequate circulation. A capillary refill longer than 3 seconds suggests impaired circulation, which is abnormal. Therefore, a capillary refill of 5 seconds is the finding the nurse should expect. Pitting edema and shortness of breath are not typically directly related to a newly applied cast and should not be expected findings in this scenario.

3. Which nursing intervention is essential for a client diagnosed with heart failure?

• A. Encourage fluid intake to prevent dehydration
• B. Monitor the client's weight daily to assess fluid balance
• C. Increase sodium intake to prevent fluid retention
• D. Limit fluid intake to avoid overload

Correct answer: B

Rationale: The correct answer is to monitor the client's weight daily to assess fluid balance in clients with heart failure. This intervention helps healthcare providers evaluate fluid retention or loss, which is crucial in managing heart failure. Choice A is incorrect because excessive fluid intake can worsen heart failure symptoms by causing fluid overload. Choice C is incorrect because increasing sodium intake can lead to fluid retention, exacerbating heart failure. Choice D is incorrect as limiting fluid intake excessively can also be harmful in heart failure management, potentially leading to dehydration.

4. A nurse is caring for a client following an acute myocardial infarction. The client is concerned that providing self-care will be difficult due to extreme fatigue. Which of the following strategies should the nurse implement to promote the client's independence?

• A. Request an occupational therapy consult to determine the need for assistive devices
• B. Assign assistive personnel to perform self-care tasks for the client
• C. Instruct the client to focus on gradually resuming self-care tasks
• D. Ask the client if a family member is available to assist with his care

Correct answer: C

Rationale: Instructing the client to focus on gradually resuming self-care tasks is the most appropriate strategy to promote independence following an acute myocardial infarction. This approach allows the client to regain confidence and control over their self-care activities without feeling overwhelmed. Requesting an occupational therapy consult (Choice A) may be beneficial but is not the immediate solution to promote independence. Assigning assistive personnel (Choice B) to perform tasks for the client does not encourage independence. Asking if a family member is available for assistance (Choice D) does not directly promote the client's independence.

5. During a presentation on basic first aid, a nurse educator evaluates a newly licensed home health nurse's understanding of heat stroke. Which symptom indicates the client has heat stroke?

• A. Hypotension
• B. Bradycardia
• C. Clammy skin
• D. Bradypnea

Correct answer: A

Rationale: The correct answer is A: Hypotension. Heat stroke can lead to hypotension, which is low blood pressure. This is a common symptom of heat stroke and requires immediate intervention. Bradycardia (slow heart rate), clammy skin, and bradypnea (slow breathing) are not typically associated with heat stroke. In heat stroke, the body's temperature regulation system fails, leading to a rapid rise in body temperature, which can cause various symptoms including hypotension.

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