Nursing Elites

1. A client has a new diagnosis of hypertension and is being taught about lifestyle changes by a nurse. Which of the following instructions should the nurse include?

• A. Increase your sodium intake to 3,000 mg per day.
• B. Exercise for 30 minutes at least 5 days a week.
• C. Sleep for at least 10 hours each night.
• D. Limit your fluid intake to 1 liter per day.

Correct answer: B

Rationale: The correct answer is B: "Exercise for 30 minutes at least 5 days a week." Regular exercise helps promote cardiovascular health and manage hypertension. Choice A is incorrect because increasing sodium intake is not recommended for hypertension. Choice C is incorrect because while sleep is important, excessive sleep duration is not typically part of hypertension management. Choice D is incorrect because fluid intake should be adequate unless advised otherwise by a healthcare provider.

2. A healthcare provider is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which finding should the healthcare provider identify as a contraindication to the administration of clozapine?

• A. Heart rate 58/min.
• B. Fasting blood glucose 100 mg/dL.
• C. Hgb 14 g/dL.
• D. WBC count 2,900/mm3.

Correct answer: D

Rationale: The correct answer is D: a low WBC count. Clozapine can suppress bone marrow function, leading to a decreased white blood cell count. This condition, known as agranulocytosis, increases the risk of severe infections. Monitoring WBC counts is essential during clozapine therapy. Choices A, B, and C are within normal ranges and are not contraindications for administering clozapine.

3. A nurse is assessing a newborn's heart rate. Which of the following actions should the nurse take?

• A. Auscultate the apical pulse and count for 1 minute
• B. Place a sensor on the index finger
• C. Heat the skin prior to placing the probe
• D. Recheck after 10 minutes

Correct answer: A

Rationale: Corrected Rationale: Auscultating the apical pulse and counting for one minute is the appropriate method to accurately measure a newborn's heart rate. The apical pulse is located at the point of maximum impulse (PMI), which is usually at the fourth or fifth intercostal space along the mid-clavicular line. This method allows for a precise assessment of the newborn's heart rate. Choice B, placing a sensor on the index finger, is incorrect because this method is more suitable for measuring oxygen saturation rather than heart rate. Choice C, heating the skin prior to placing the probe, is unnecessary for assessing heart rate and may lead to potential burns in newborns. Choice D, rechecking after 10 minutes, is not appropriate as immediate assessment and intervention may be required if an abnormal heart rate is detected in a newborn.

4. What is the primary action when caring for a patient with a stage 3 pressure ulcer?

• A. Apply a hydrocolloid dressing
• B. Provide wound debridement
• C. Change the dressing daily
• D. Apply moist gauze to the ulcer

Correct answer: A

Rationale: The correct answer is to apply a hydrocolloid dressing. This type of dressing helps maintain a moist environment that is conducive to healing in stage 3 pressure ulcers. Providing wound debridement (choice B) is more suitable for higher stages of pressure ulcers where there is necrotic tissue. Changing the dressing daily (choice C) may be necessary but is not the primary action for a stage 3 pressure ulcer. Applying moist gauze (choice D) is not the recommended approach as it does not provide the same benefits as a hydrocolloid dressing.

5. What is the priority nursing action for a patient with shortness of breath?

• A. Administer oxygen
• B. Reposition the patient
• C. Check oxygen saturation
• D. Elevate the head of the bed

Correct answer: A

Rationale: Administering oxygen is the priority nursing action for a patient experiencing shortness of breath. Oxygen therapy aims to improve oxygenation levels quickly, addressing the underlying cause of the symptom. Repositioning the patient, checking oxygen saturation, and elevating the head of the bed are important interventions but administering oxygen takes precedence in this scenario to ensure adequate oxygen supply to the body.

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