Nursing Elites

1. A client with heart failure is receiving discharge teaching from a nurse. Which of the following client statements indicates an understanding of the teaching?

• A. I should weigh myself once a week.
• B. I should limit my fluid intake to 1 liter per day.
• C. I should report a weight gain of 2 pounds in one day.
• D. I should reduce my protein intake to prevent fluid retention.

Correct answer: C

Rationale: The correct answer is C. Reporting a sudden weight gain of 2 pounds in one day is crucial in managing heart failure because it can indicate fluid retention, a common symptom in heart failure. Option A is incorrect as weighing oneself once a week may not provide timely information about fluid retention. Option B is incorrect because fluid intake restriction is individualized and generally involves more specific guidance. Option D is incorrect as protein intake is important but reducing it solely to avoid fluid retention is not the primary focus in heart failure management.

2. What is the appropriate action for a patient experiencing a severe allergic reaction?

• A. Administer epinephrine
• B. Administer antihistamines
• C. Administer corticosteroids
• D. Administer oxygen

Correct answer: A

Rationale: The correct answer is to administer epinephrine. Epinephrine is the first-line treatment for severe allergic reactions as it helps reverse the symptoms rapidly by constricting blood vessels, increasing heart rate, and opening airways. Antihistamines (Choice B) may help with mild allergic reactions but are not effective for severe cases. Corticosteroids (Choice C) are used to reduce inflammation and are typically not the first-line treatment for acute severe allergic reactions. Administering oxygen (Choice D) may be necessary to support breathing in severe cases, but epinephrine is the primary treatment to reverse the allergic reaction symptoms.

3. A nurse is providing teaching to a client who has a new prescription for an albuterol inhaler. Which of the following instructions should the nurse include?

• A. Take one puff every 5 minutes until symptoms improve.
• B. Hold your breath for 10 seconds after inhaling the medication.
• C. Shake the inhaler for 2 seconds before use.
• D. Exhale forcefully after each puff.

Correct answer: B

Rationale: The correct answer is B. Instructing the client to hold their breath for 10 seconds after inhaling the medication allows it to reach deeper into the lungs for maximum effectiveness. Choice A is incorrect because taking one puff every 5 minutes may lead to overuse of the medication. Choice C is incorrect as shaking the inhaler for only 2 seconds may not provide adequate mixing of the medication. Choice D is incorrect because exhaling forcefully after each puff may reduce the amount of medication that reaches the lungs.

4. A nurse is caring for a client who has Cushing's syndrome. Which of the following findings should the nurse expect?

• A. Hypotension.
• B. Weight loss.
• C. Hyperkalemia.
• D. Hypercalcemia.

Correct answer: C

Rationale: In clients with Cushing's syndrome, the nurse should expect hyperkalemia. Cushing's syndrome is characterized by excess cortisol levels, which can lead to potassium retention and result in hyperkalemia. Choices A, B, and D are incorrect. Hypotension is not typically associated with Cushing's syndrome; instead, hypertension is more common due to the effects of cortisol. Weight gain, rather than weight loss, is a common symptom of Cushing's syndrome. Hypercalcemia is not a typical finding in Cushing's syndrome; instead, hypocalcemia may occur due to increased urinary calcium excretion.

5. A client who has a new prescription for lithium is receiving teaching from a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. ''I will avoid eating foods that contain tyramine.''
• B. ''I should increase my salt intake while taking this medication.''
• C. ''I should drink at least 2 liters of water each day while taking this medication.''
• D. ''I should avoid consuming caffeinated beverages while taking this medication.''

Correct answer: C

Rationale: The correct answer is C. Drinking at least 2 liters of water daily is crucial for clients taking lithium to prevent dehydration and lithium toxicity. Lithium is a salt, so it's important for clients to maintain adequate hydration. Option A is incorrect because lithium does not interact with tyramine-containing foods. Option B is incorrect because increasing salt intake is not necessary and can actually exacerbate lithium toxicity. Option D is incorrect because avoiding caffeinated beverages is not a priority teaching point for clients taking lithium.

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