Nursing Elites

1. A nurse is providing discharge teaching to a client following a heart transplant. Which of the following information should the nurse include in the teaching?

• A. Immunosuppressant medications need to be taken for up to 1 year
• B. Shortness of breath might be an indication of transplant rejection
• C. The surgical site will heal in 3 to 4 weeks after surgery
• D. Begin 45 minutes of moderate aerobic exercise per day following discharge

Correct answer: B

Rationale: The correct answer is B. Shortness of breath is an important sign of transplant rejection. Other manifestations of rejection include fatigue, edema, bradycardia, and hypotension. Choices A, C, and D are incorrect because: A) Immunosuppressant medications are typically required for life, not just up to 1 year. C) The surgical site healing time can vary and may take longer than 3 to 4 weeks. D) Starting a specific exercise regimen should be individualized and guided by healthcare providers; a general recommendation like 45 minutes of exercise per day may not be suitable for all heart transplant recipients.

2. What should a healthcare provider monitor for in a patient with hypokalemia?

• A. Monitor for muscle weakness
• B. Monitor for bradycardia
• C. Check deep tendon reflexes
• D. Monitor for hyperglycemia

Correct answer: A

Rationale: Corrected Rationale: Muscle weakness is a common symptom of hypokalemia and should be closely monitored in affected patients. Hypokalemia is a condition characterized by low potassium levels in the blood, which can lead to muscle weakness, cramps, and even paralysis. While bradycardia (slow heart rate) can be associated with severe hypokalemia, monitoring for muscle weakness is more specific to the condition. Checking deep tendon reflexes is not typically a primary monitoring parameter for hypokalemia. Monitoring for hyperglycemia is not directly related to hypokalemia, as hypokalemia is primarily associated with potassium levels in the blood.

3. What should the nurse do when a patient experiences abdominal cramping during enema administration?

• A. Lower the height of the enema solution container
• B. Stop the procedure and remove the tubing
• C. Continue the enema at a slower rate
• D. Increase the flow of the enema solution

Correct answer: A

Rationale: When a patient experiences abdominal cramping during enema administration, the nurse should lower the height of the enema solution container. Lowering the height helps relieve cramping by slowing down the flow of the enema, reducing discomfort for the patient. Choice B, stopping the procedure and removing the tubing, is incorrect as it does not directly address the cramping issue. Choice C, continuing the enema at a slower rate, could potentially worsen the cramping by prolonging the discomfort. Choice D, increasing the flow of the enema solution, is also incorrect as it may intensify the cramping and cause more discomfort to the patient.

4. A patient reports abdominal cramping during an enema administration. What action should the nurse take?

• A. Increase the flow of the enema
• B. Lower the height of the enema solution container
• C. Stop the enema procedure
• D. Remove the enema tubing

Correct answer: B

Rationale: When a patient experiences abdominal cramping during an enema administration, the nurse should lower the height of the enema solution container. Lowering the container helps to relieve cramping by slowing the flow of the solution, making it more comfortable for the patient. Increasing the flow (Choice A) would exacerbate the cramping. Stopping the procedure (Choice C) may not be necessary if adjusting the height resolves the issue. Removing the enema tubing (Choice D) is not the initial action indicated for cramping; adjusting the height is the more appropriate intervention.

5. What are the expected manifestations in a patient experiencing a thrombotic stroke?

• A. Sudden numbness or loss of function on one side of the body
• B. Sudden loss of consciousness and seizure
• C. Gradual onset of difficulty speaking
• D. Loss of sensation in the affected limb

Correct answer: A

Rationale: The correct manifestation in a patient experiencing a thrombotic stroke is sudden numbness or loss of function on one side of the body. This is due to the blockage of a blood vessel by a clot, leading to a lack of blood flow to a specific part of the brain. Choices B, C, and D are incorrect. Sudden loss of consciousness and seizure are more commonly associated with hemorrhagic strokes. Gradual onset of difficulty speaking is often seen in ischemic strokes affecting language areas, not specifically in thrombotic strokes. Loss of sensation in the affected limb is more indicative of sensory nerve damage rather than the motor deficits seen in thrombotic strokes.

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