Nursing Elites

1. A nurse is caring for a client who has Raynaud's disease. Which action should the nurse take?

• A. Provide information about stress management.
• B. Maintain a warm temperature in the client's room.
• C. Administer epinephrine for acute episodes.
• D. Give glucocorticoid steroids twice a day.

Correct answer: A

Rationale: The correct action for the nurse to take when caring for a client with Raynaud's disease is to provide information about stress management. Raynaud's disease is a condition where the blood vessels narrow in response to cold or stress, leading to reduced blood flow to certain areas of the body, usually the fingers and toes. Stress management helps reduce triggers for Raynaud's disease by minimizing emotional stress, which can trigger vasospasms. Choice B is incorrect as maintaining a warm temperature, rather than a cool one, is recommended for individuals with Raynaud's disease to prevent triggering vasospasms. Choice C is incorrect because epinephrine is not typically used to manage Raynaud's disease, as it can further constrict blood vessels. Choice D is incorrect as glucocorticoid steroids are not a first-line treatment for Raynaud's disease.

2. A nurse is assessing a client who is receiving enteral feedings through a nasogastric tube. Which of the following findings requires immediate intervention?

• A. Aspirating 100 mL of gastric residual
• B. Gastric pH of 4
• C. Auscultating crackles in the lung bases
• D. Checking residual every 6 hours

Correct answer: C

Rationale: Auscultating crackles in the lung bases indicates fluid in the lungs, which can be a sign of aspiration pneumonia or pulmonary edema and requires immediate intervention to prevent respiratory distress. Aspirating 100 mL of gastric residual is within the acceptable range and does not require immediate intervention. A gastric pH of 4 is normal for gastric contents. Checking residual every 6 hours is a routine nursing intervention and does not indicate an urgent issue like pulmonary complications.

3. A nurse is providing discharge teaching to a client who is recovering from a myocardial infarction. Which of the following client statements indicates a need for further teaching?

• A. I will take a daily aspirin to prevent another heart attack.
• B. I should expect to experience chest pain when I exercise.
• C. I will increase my intake of saturated fats.
• D. I will participate in a cardiac rehabilitation program.

Correct answer: C

Rationale: The correct answer is C. Increasing the intake of saturated fats can raise cholesterol levels, which is not recommended after a myocardial infarction. Choices A, B, and D are all appropriate statements indicating a good understanding of post-myocardial infarction care. Taking a daily aspirin can help prevent another heart attack, experiencing chest pain with exercise is a common expectation post-myocardial infarction, and participating in a cardiac rehabilitation program is important for recovery and improving heart health.

4. A nurse is reviewing the medical record of a client who is at 30 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?

• A. Blood pressure 140/90 mm Hg
• B. 1+ pitting edema in the lower extremities
• C. Weight gain of 2.3 kg (5 lb) in 1 week
• D. Mild headache

Correct answer: C

Rationale: A weight gain of 2.3 kg (5 lb) in 1 week can indicate worsening preeclampsia due to fluid retention, which can lead to serious complications. This finding should be reported promptly to the provider for further assessment and intervention. Blood pressure of 140/90 mm Hg is high but may not be an immediate concern for a client with preeclampsia at 30 weeks. 1+ pitting edema in the lower extremities is common in pregnancy, especially in the third trimester, and may not be a significant finding in isolation. A mild headache can be a common symptom in pregnancy and may not be indicative of worsening preeclampsia unless accompanied by other concerning signs.

5. A nurse is caring for a client who is postoperative following a total knee arthroplasty. Which of the following actions should the nurse take?

• A. Place a pillow under the client's knees
• B. Keep the client's legs elevated
• C. Flex the client's knee every 2 hours
• D. Apply heat to the operative knee

Correct answer: B

Rationale: Keeping the client's legs elevated is the appropriate action to prevent venous thromboembolism following a total knee arthroplasty. Elevating the legs helps promote circulation and reduce the risk of blood clots. Placing a pillow under the client's knees may provide comfort but does not address the specific postoperative complication. Flexing the client's knee every 2 hours may be contraindicated as excessive movement can disrupt the surgical site. Applying heat to the operative knee is not recommended immediately postoperatively as it can increase swelling and discomfort.

Similar Questions