Nursing Elites

1. A client with heart failure is being taught about dietary modifications by a nurse. Which of the following client statements indicates an understanding of the teaching?

• A. I will increase my intake of canned vegetables.
• B. I will limit my daily sodium intake to 2 grams.
• C. I will increase my intake of whole grains.
• D. I will reduce my intake of processed meats.

Correct answer: D

Rationale: The correct answer is 'D: I will reduce my intake of processed meats.' This choice indicates an understanding of the teaching because processed meats are high in sodium, which can worsen heart failure due to fluid retention. Choices A, B, and C do not directly address the issue of reducing sodium intake, which is crucial for clients with heart failure. Increasing canned vegetable intake (A) may not always be advisable due to potential high sodium content in canned products. Limiting sodium intake to 2 grams daily (B) is a good practice, but it's more specific to sodium restriction rather than addressing the source of sodium like processed meats. Increasing whole grains (C) is generally beneficial but does not directly relate to reducing sodium intake in heart failure clients.

2. When a client with schizophrenia who experiences auditory hallucinations says, 'It's hard not to listen to the voices,' which question should the nurse ask?

• A. Do you understand that the voices are not real?
• B. Why do you think the voices are talking to you?
• C. Have you tried going to a private place when this occurs?
• D. What helps you ignore what you are hearing?

Correct answer: D

Rationale: The correct question for the nurse to ask the client who experiences auditory hallucinations and finds it hard not to listen to the voices is, 'What helps you ignore what you are hearing?' This question focuses on promoting coping strategies and therapeutic communication, encouraging the client to share what techniques or interventions have been effective for managing the auditory hallucinations. Choice A is incorrect because it assumes the client does not understand that the voices are not real, which may not be the case. Choice B delves into the reasons behind the voices, which may not be immediately helpful in managing the current situation. Choice C suggests a physical solution of going to a private place, which may not address the underlying issue of coping with the voices.

3. A nurse is assessing a client who is receiving digoxin for heart failure. Which of the following findings should the nurse report to the provider?

• A. Heart rate 68/min.
• B. Blood pressure 110/70 mm Hg.
• C. Vision changes.
• D. Respiratory rate 18/min.

Correct answer: C

Rationale: Corrected Rationale: Vision changes are a common sign of digoxin toxicity, which can be serious and should be reported to the provider immediately. Changes in heart rate, blood pressure, or respiratory rate are not typically associated with digoxin toxicity. Therefore, the nurse should prioritize reporting vision changes to ensure prompt assessment and intervention.

4. A nurse is preparing to administer a rectal suppository to a client. What action should the nurse take?

• A. Encourage the client to hold their breath as long as possible.
• B. Insert the suppository just past the anal sphincter.
• C. Lubricate the suppository and insert it 1.5 cm (0.6 in) into the rectum.
• D. Place the client in a Sims' position before inserting the suppository.

Correct answer: D

Rationale: The correct action the nurse should take when administering a rectal suppository is to place the client in a Sims' position. This position helps facilitate the proper administration of the suppository by allowing better access to the rectum. Encouraging the client to hold their breath as long as possible (Choice A) is unnecessary and not related to the administration of a rectal suppository. Inserting the suppository just past the anal sphincter (Choice B) is incorrect as it may not reach the rectum where it needs to be placed. Lubricating the suppository and inserting it 1.5 cm into the rectum (Choice C) is incorrect as the suppository needs to be inserted deeper into the rectum for proper absorption.

5. A nurse is providing discharge teaching to a client who has a new prescription for enoxaparin. Which of the following instructions should the nurse include?

• A. Avoid eating spinach while taking this medication.
• B. Massage the injection site after administration.
• C. Administer the injection into the deltoid muscle.
• D. Inject the medication into the abdomen.

Correct answer: D

Rationale: The correct answer is to inject the medication into the abdomen. Enoxaparin should be administered subcutaneously into the abdomen for optimal absorption. Choice A is incorrect as there is no specific interaction between enoxaparin and spinach. Choice B is incorrect as massaging the injection site after administration is not recommended and can increase bruising. Choice C is incorrect as enoxaparin injections should not be administered into the deltoid muscle.

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