Nursing Elites

1. A healthcare professional is assessing a client with a history of heart disease. Which of the following findings should the healthcare professional monitor?

• A. Blood pressure
• B. Weight
• C. Heart rhythm
• D. All of the above

Correct answer: D

Rationale: Monitoring blood pressure, weight, and heart rhythm is crucial in clients with a history of heart disease as these parameters can indicate changes in the cardiovascular status. Changes in blood pressure can signify heart strain, weight fluctuations can be related to fluid retention or heart failure, and irregular heart rhythm can indicate arrhythmias or other cardiac issues. Monitoring all these parameters comprehensively allows for early detection of potential complications and timely intervention. Therefore, selecting 'All of the above' is the correct choice as it encompasses all the essential parameters for monitoring in clients with heart disease. Choices A, B, and C are incorrect as monitoring only one or two of these parameters may lead to missing important changes in the client's condition.

2. A nurse is caring for a newborn in the nursery following a circumcision. The newborn's grandparent, who does not have an identification bracelet, requests to take the newborn to his mother's room. What action should the nurse take?

• A. Notify security.
• B. Respectfully deny the grandparent’s request.
• C. Contact the mother for verification.
• D. Escort the grandparent and newborn to the room.

Correct answer: B

Rationale: The correct action for the nurse to take is to respectfully deny the grandparent's request. In healthcare settings, strict security protocols are in place to ensure the safety of newborns. Only individuals with proper identification bracelets are allowed to transport newborns to prevent unauthorized individuals from taking them. Contacting the mother for verification would be time-consuming and may not be feasible immediately. Escorting the grandparent and newborn without proper identification would violate security protocols and compromise the newborn's safety. Notifying security should be done only if there is a threat or concern for safety, which is not the case in this scenario. Therefore, the best course of action is for the nurse to respectfully deny the grandparent's request to uphold the safety and security measures in place.

3. A client just received the first dose of lisinopril. Which of the following is an appropriate nursing intervention?

• A. Place the client on cardiac monitoring
• B. Monitor the client's oxygen saturation level
• C. Provide standby assistance when getting out of bed
• D. Encourage foods high in potassium

Correct answer: C

Rationale: The correct answer is to provide standby assistance when getting out of bed. Lisinopril can cause first-dose hypotension, leading to dizziness and increasing the risk of falls. Standby assistance helps ensure the client's safety when mobilizing. Placing the client on cardiac monitoring (choice A) is not necessary unless there are specific indications for cardiac monitoring. Monitoring oxygen saturation (choice B) is not directly related to the side effects of lisinopril. Encouraging foods high in potassium (choice D) is not the most immediate or appropriate intervention following the administration of lisinopril.

4. A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following interventions should the nurse implement?

• A. Encourage frequent ambulation
• B. Administer lorazepam
• C. Provide a low-calorie diet
• D. Administer insulin as prescribed

Correct answer: B

Rationale: The correct intervention for a client experiencing alcohol withdrawal is to administer lorazepam. Lorazepam, a benzodiazepine, is commonly used to manage the symptoms of alcohol withdrawal by preventing seizures and reducing agitation and anxiety. Encouraging frequent ambulation (choice A) may not be safe during alcohol withdrawal due to potential instability and confusion. Providing a low-calorie diet (choice C) is not a priority during alcohol withdrawal, as the focus is on managing withdrawal symptoms. Administering insulin as prescribed (choice D) is unrelated to managing alcohol withdrawal symptoms.

5. A client expresses anxiety about an upcoming surgery. What should the nurse do?

• A. Reassure the client that everything will be fine
• B. Ask the client to describe feelings
• C. Tell the client to stay positive
• D. Provide information about the surgery

Correct answer: B

Rationale: Asking the client to describe their feelings is the most appropriate action for the nurse to take. This allows the nurse to understand the specific concerns and anxieties the client is experiencing. Choice A may invalidate the client's feelings and not address the root cause of anxiety. Choice C may come across as dismissive and oversimplified. While providing information about the surgery (Choice D) is important, addressing the client's emotional state is the initial priority in this situation.

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