Nursing Elites

1. A client with coronary artery disease (CAD) is taking a low-dose aspirin daily. The nurse is reinforcing teaching with the client. The nurse should include that this medication has which of the following therapeutic effects?

• A. Analgesic
• B. Antiplatelet
• C. Anticoagulant
• D. Thrombolytic

Correct answer: B

Rationale: The correct answer is B: Antiplatelet. Aspirin works by inhibiting platelet aggregation, making it an antiplatelet agent. This effect helps reduce the risk of blood clot formation in clients with CAD. Choice A, Analgesic, is incorrect because aspirin's primary action in this context is not pain relief. Choice C, Anticoagulant, is incorrect as aspirin does not directly inhibit coagulation factors. Choice D, Thrombolytic, is incorrect as aspirin does not actively break down clots but rather prevents their formation.

2. What are early indicators of dehydration?

• A. Dry mouth
• B. Increased thirst
• C. Decreased urine output
• D. Dizziness

Correct answer: A

Rationale: The correct answer is A, dry mouth, and B, increased thirst are early indicators of dehydration. Dry mouth occurs when the body is dehydrated, and increased thirst is the body's way of trying to increase fluid intake to combat dehydration. Choices C and D, decreased urine output and dizziness, can be signs of severe dehydration but are not typically considered early indicators.

3. Which of the following interventions is most appropriate for a client with left-leg weakness who is learning to use a cane?

• A. Maintain two points of support on the floor at all times
• B. Use the cane on the weak side of the body
• C. Advance the cane and the strong leg simultaneously
• D. Advance the cane 30 to 45 cm (12-18 in) with each step

Correct answer: A

Rationale: The most appropriate intervention for a client with left-leg weakness learning to use a cane is to maintain two points of support on the floor at all times. This ensures stability and helps distribute weight evenly between the legs, reducing the risk of falls. Using the cane on the weak side of the body (Choice B) may not provide adequate support. Advancing the cane and the strong leg simultaneously (Choice C) can lead to imbalance and increases the risk of falls. Advancing the cane too far with each step (Choice D) can also compromise balance and stability.

4. What are the early signs of diabetic ketoacidosis?

• A. Excessive thirst and fruity breath odor
• B. Weight loss and increased urination
• C. Nausea and vomiting
• D. Hypoglycemia and fatigue

Correct answer: A

Rationale: The correct answer is A: Excessive thirst and fruity breath odor. Diabetic ketoacidosis presents with these early signs due to ketone buildup in the body. Choice B, weight loss and increased urination, are more characteristic of uncontrolled diabetes but not specific to diabetic ketoacidosis. Choice C, nausea and vomiting, can occur in diabetic ketoacidosis but are not as early or specific as excessive thirst and fruity breath odor. Choice D, hypoglycemia and fatigue, are not typical signs of diabetic ketoacidosis; rather, diabetic ketoacidosis usually presents with hyperglycemia.

5. A client with type 2 diabetes mellitus is being taught about insulin administration by a nurse. Which of the following instructions should the nurse include?

• A. Inject insulin into the muscle
• B. Rotate injection sites with each dose
• C. Store insulin at room temperature
• D. Massage the injection site after administration

Correct answer: B

Rationale: The correct instruction that the nurse should include is to rotate injection sites with each dose. This practice is essential to prevent tissue damage and ensure proper insulin absorption. Option A is incorrect because insulin should not be injected into the muscle, but rather into the subcutaneous tissue. Option C is incorrect as insulin should be stored in the refrigerator to maintain its effectiveness. Option D is incorrect as massaging the injection site after administration can lead to faster absorption and potentially hypoglycemia.

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