Nursing Elites

1. A nurse is teaching a client who has peripheral arterial disease (PAD) about exercise recommendations. Which of the following instructions should the nurse include?

• A. Exercise to the point of pain
• B. Stop exercising if pain occurs
• C. Exercise only once per week
• D. Avoid walking to prevent pain

Correct answer: B

Rationale: The correct instruction the nurse should include is to 'Stop exercising if pain occurs.' In peripheral arterial disease (PAD), it is crucial to avoid exercising to the point of pain as this may worsen the condition and lead to complications. Exercising to the point of pain can result in inadequate blood flow to the extremities, causing further damage. By stopping exercise if pain occurs, the client can prevent exacerbating their condition. Choices A, C, and D are incorrect because exercising to the point of pain, limiting exercise to once per week, and avoiding walking altogether are not recommended strategies for managing PAD and could potentially harm the client.

2. What are the early signs of heart failure in a patient?

• A. Shortness of breath and weight gain
• B. Fatigue and chest pain
• C. Nausea and vomiting
• D. Cough and elevated blood pressure

Correct answer: A

Rationale: The correct answer is A: Shortness of breath and weight gain. Early signs of heart failure typically manifest as shortness of breath due to fluid accumulation in the lungs and weight gain due to fluid retention in the body. Choices B, C, and D are incorrect. Fatigue and chest pain are symptoms commonly associated with heart conditions but are not specific early signs of heart failure. Nausea and vomiting are not typically early signs of heart failure. Cough can be a symptom of heart failure, but it is usually associated with other symptoms like shortness of breath rather than being an isolated early sign. Elevated blood pressure is not an early sign of heart failure; in fact, heart failure is more commonly associated with low blood pressure.

3. What should a person recommend to a client experiencing constipation?

• A. Increase fluid intake to prevent further dehydration
• B. Increase dietary fiber to promote regular bowel movements
• C. Administer a laxative to relieve constipation
• D. Encourage bed rest to allow for bowel function to return

Correct answer: B

Rationale: Increasing dietary fiber is an effective recommendation for clients experiencing constipation as it helps promote regular bowel movements. Choice A, increasing fluid intake, is also important but the most appropriate initial recommendation for constipation is to increase dietary fiber. Choice C, administering a laxative, should not be the first-line recommendation and is typically considered after dietary and lifestyle interventions. Choice D, encouraging bed rest, does not directly address constipation relief or prevention.

4. How should a healthcare provider manage a patient with hypertensive crisis?

• A. Administer antihypertensive medications and monitor blood pressure
• B. Provide a high-sodium diet and fluid restriction
• C. Administer diuretics and provide oxygen therapy
• D. Provide IV fluids and monitor for kidney failure

Correct answer: A

Rationale: In a hypertensive crisis, the immediate goal is to lower blood pressure to prevent organ damage. Administering antihypertensive medications helps achieve this goal efficiently. Monitoring blood pressure is essential to assess the effectiveness of the treatment and adjust medication as needed. Providing a high-sodium diet and fluid restriction (Choice B) can exacerbate hypertension by increasing blood pressure. Diuretics and oxygen therapy (Choice C) are not the first-line treatment for hypertensive crisis, as the priority is rapid blood pressure reduction. Providing IV fluids and monitoring for kidney failure (Choice D) are not primary interventions for managing hypertensive crisis; the focus is on blood pressure control and organ protection.

5. What are the nursing considerations for a patient receiving anticoagulant therapy?

• A. Monitor INR levels and check for bleeding
• B. Educate patient on dietary restrictions
• C. Ensure adequate hydration and nutrition
• D. Ensure that the patient remains immobile

Correct answer: A

Rationale: The correct answer is A: 'Monitor INR levels and check for bleeding.' When a patient is receiving anticoagulant therapy, nurses must monitor the patient's INR levels to ensure that the anticoagulants are within the therapeutic range and also watch for signs of bleeding, which is a common side effect of anticoagulants. Option B is incorrect because while patient education is important, dietary restrictions are not a direct nursing consideration when administering anticoagulant therapy. Option C is not a specific nursing consideration related to anticoagulant therapy. Option D is incorrect as keeping the patient immobile is not a standard nursing practice for patients on anticoagulant therapy, as mobility is often encouraged to prevent complications like deep vein thrombosis.

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