Nursing Elites

1. A client with hypertension is being educated on lifestyle changes by a nurse. Which recommendation is the most important to reduce blood pressure?

• A. Increase water intake
• B. Avoid alcohol consumption
• C. Exercise regularly
• D. Reduce sodium intake

Correct answer: D

Rationale: Reducing sodium intake is crucial in managing hypertension as high sodium levels can lead to fluid retention and increased blood pressure. While increasing water intake is beneficial for overall health, reducing sodium has a more significant impact on blood pressure. Regular exercise is important for cardiovascular health but does not have as direct an impact on blood pressure as sodium reduction. Avoiding alcohol is also important, but in terms of managing blood pressure, reducing sodium intake takes precedence.

2. A client with hypoglycemia is unresponsive. What is the nurse's priority action?

• A. Administer intravenous dextrose.
• B. Check the client's blood glucose level.
• C. Administer glucagon intramuscularly.
• D. Prepare to administer oral glucose.

Correct answer: C

Rationale: The correct answer is to administer glucagon intramuscularly. In an unresponsive hypoglycemic client, administering glucagon intramuscularly is the priority action as it helps raise blood glucose levels quickly. Intravenous dextrose may be challenging to administer in an unresponsive client. Checking the client's blood glucose level is important but not the priority when the client is unresponsive. Preparing to administer oral glucose is not ideal for an unresponsive client as they may not be able to swallow.

3. A nurse finds a pregnant client at 33 weeks gestation in cardiac arrest. What modification to cardiopulmonary resuscitation (CPR) should the nurse implement?

• A. Administer chest compressions at a faster rate.
• B. Position a firm wedge under the client’s pelvis and thorax at a 30-degree tilt.
• C. Position the client flat with legs elevated.
• D. Call for immediate assistance and prepare for a cesarean section.

Correct answer: B

Rationale: In a pregnant client at 33 weeks gestation, performing CPR requires tilting the pelvis and thorax at a 30-degree angle to relieve pressure on the vena cava, ensuring proper circulation during compressions. Administering chest compressions at a faster rate (Choice A) may not address the specific needs of a pregnant client in cardiac arrest. Positioning the client flat with legs elevated (Choice C) is not recommended as it can worsen vena cava compression. Calling for immediate assistance and preparing for a cesarean section (Choice D) should be considered only after initiating appropriate CPR modifications.

4. A client recently started on warfarin therapy. What laboratory value is most important to monitor for this client?

• A. Platelet count
• B. Prothrombin time (PT)
• C. Creatinine level
• D. Blood urea nitrogen (BUN)

Correct answer: B

Rationale: Prothrombin time (PT) is the most important laboratory value to monitor for clients on warfarin therapy. PT helps determine how long it takes blood to clot and ensures the warfarin dose is within the therapeutic range to prevent either excessive bleeding or clotting. Monitoring platelet count is important for assessing the risk of bleeding, but PT is more specific to warfarin therapy. Creatinine level and BUN are indicators of kidney function and are not directly related to warfarin therapy.

5. A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is?

• A. Difference in the intake and output
• B. Changes in the mucous membranes
• C. Skin turgor
• D. Weekly weight

Correct answer: D

Rationale: In clients with altered renal function being treated at home, weekly weight is the most accurate indicator of fluid balance. Fluid retention or loss can significantly affect weight, making it a reliable measure. Choices A, B, and C are not as accurate indicators of fluid balance as weekly weight. Intake and output differences can vary in accuracy and may not capture all aspects of fluid balance. Changes in mucous membranes and skin turgor can be influenced by factors other than fluid balance, making them less precise indicators.

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