Nursing Elites

1. A client who has a new prescription for lisinopril is being taught by a nurse. Which of the following client statements indicates an understanding of the teaching?

• A. I should avoid using salt substitutes while taking this medication.
• B. I should take this medication with food to prevent nausea.
• C. I should increase my intake of potassium-rich foods while taking this medication.
• D. I should limit my fluid intake while taking this medication.

Correct answer: A

Rationale: The correct answer is A. Lisinopril can increase potassium levels, so clients should avoid salt substitutes that contain potassium. Choice B is incorrect because lisinopril is usually taken on an empty stomach. Choice C is incorrect because lisinopril can lead to hyperkalemia, so increasing potassium-rich foods is not recommended. Choice D is incorrect because lisinopril can cause increased urination, so fluid intake should not be limited.

2. A nurse is caring for a client with Alzheimer's disease who wanders frequently. Which of the following interventions should the nurse include in the plan of care?

• A. Place the client in a well-lit area to reduce wandering.
• B. Ensure that the client wears an identification bracelet at all times.
• C. Keep the client's bed in the lowest position.
• D. Use physical restraints to prevent wandering.

Correct answer: B

Rationale: The correct answer is to ensure that the client wears an identification bracelet at all times. This intervention helps staff recognize clients who wander and ensures their safety. Placing the client in a well-lit area (Choice A) may be helpful in some cases but does not directly address the issue of wandering. Keeping the client's bed in the lowest position (Choice C) is important for fall prevention but is not directly related to wandering behavior. Using physical restraints (Choice D) is not recommended as the first-line intervention for wandering and should be avoided due to ethical concerns and potential risks.

3. A client receiving radiation therapy for breast cancer may experience which of the following side effects that the nurse should monitor for?

• A. Fatigue
• B. Nausea
• C. Skin irritation
• D. Weight gain

Correct answer: C

Rationale: During radiation therapy for breast cancer, one common side effect is skin irritation due to the impact of radiation on the skin cells. This side effect should be closely monitored by the nurse. Fatigue may also occur as a side effect of radiation therapy, but skin irritation is more specific to the treatment area and is a priority in this case. Nausea and weight gain are not typically associated with radiation therapy for breast cancer, making them incorrect choices.

4. How should a healthcare provider monitor a patient with fluid overload?

• A. Monitor daily weight
• B. Check for edema
• C. Monitor input and output
• D. Monitor blood pressure

Correct answer: A

Rationale: Monitoring daily weight is crucial in assessing fluid retention accurately in a patient with fluid overload. Changes in weight can indicate fluid accumulation or loss, providing valuable information for healthcare providers. Checking for edema (choice B) is important but may not always accurately reflect total body fluid status. Monitoring input and output (choice C) and blood pressure (choice D) are also essential aspects of patient assessment, but they may not directly reflect the extent of fluid overload as effectively as monitoring daily weight.

5. A nurse is caring for a client who is receiving continuous enteral feedings through a nasogastric tube. Which of the following actions should the nurse take?

• A. Keep the head of the bed elevated to 15 degrees.
• B. Change the feeding bag every 48 hours.
• C. Administer the feeding through a large-bore syringe.
• D. Flush the tube with 0.9% sodium chloride every 4 hours.

Correct answer: D

Rationale: The correct action the nurse should take is to flush the tube with 0.9% sodium chloride every 4 hours. This helps maintain patency and prevents clogs during enteral feedings. Keeping the head of the bed elevated to 15 degrees (Choice A) is important for preventing aspiration but is not directly related to tube care. Changing the feeding bag every 48 hours (Choice B) is not a standard practice as the bag should be changed every 24 hours to prevent bacterial growth. Administering the feeding through a large-bore syringe (Choice C) is incorrect as enteral feedings should be given through an appropriate feeding pump for accuracy and safety.

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