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. A client is receiving IV fluids and has developed phlebitis. What is the next step the nurse should take?

• A. Monitor the site for further swelling
• B. Remove the catheter and place it in another site
• C. Reduce the flow rate of IV fluids
• D. Switch to oral hydration

Correct answer: B

Rationale: The correct next step when a client develops phlebitis while receiving IV fluids is to remove the catheter and place it in another site. Phlebitis is inflammation of a vein, and leaving the catheter in the same site can lead to further complications. Monitoring the site for further swelling, as in choice A, is not enough as the source of inflammation needs to be removed. Choice C, reducing the flow rate, may not address the underlying issue causing phlebitis. Switching to oral hydration, as in choice D, is not necessary for addressing phlebitis related to IV fluid administration.

3. A client with a peptic ulcer had a partial gastrectomy and vagotomy (Billroth I). In planning the discharge teaching, the client should be cautioned by the nurse about which of the following?

• A. Sit up for at least 30 minutes after eating
• B. Avoid fluids between meals
• C. Increase the intake of high-carbohydrate foods
• D. Avoid eating large meals that are high in simple sugars and liquids

Correct answer: D

Rationale: The correct answer is D: 'Avoid eating large meals that are high in simple sugars and liquids.' Clients who have undergone partial gastrectomy are at risk of dumping syndrome, which can occur due to the rapid emptying of stomach contents into the small intestine. Consuming large meals high in simple sugars and liquids can exacerbate this syndrome, leading to symptoms like abdominal cramping and diarrhea. Choices A, B, and C are not directly related to preventing dumping syndrome and are not the priority concerns for a client post-partial gastrectomy.

4. Which of the following interventions is the best to improve the healing of a pressure ulcer for a client with a low serum albumin level?

• A. Provide high-calorie, high-protein supplements
• B. Consult a dietitian to create a high-protein diet plan
• C. Administer nutritional supplements
• D. Increase IV fluids to prevent dehydration

Correct answer: B

Rationale: Consulting a dietitian to create a high-protein diet plan is the best intervention for a client with a low serum albumin level to promote healing. This approach ensures that the client receives the specific nutrients needed for wound healing. Providing high-calorie, high-protein supplements (choice A) may not address the specific nutritional deficiencies of the client. Administering nutritional supplements (choice C) is vague and may not target the necessary nutrients for wound healing. Increasing IV fluids (choice D) is important for hydration but does not directly address the nutritional needs of the client to improve ulcer healing.

5. A nurse is providing discharge instructions to a client with home oxygen therapy. What safety measure should the nurse emphasize?

• A. Allow smoking in designated outdoor areas
• B. Keep oxygen tanks upright and away from heat sources
• C. Store oxygen tanks in a closet when not in use
• D. Keep oxygen equipment at least 10 feet away from open flames

Correct answer: B

Rationale: The correct safety measure that the nurse should emphasize is to keep oxygen tanks upright and away from heat sources. This is crucial to prevent the risk of fire or explosion. Choice A is incorrect as smoking near oxygen can lead to a fire hazard. Choice C is also incorrect as storing oxygen tanks in enclosed spaces can be dangerous. Choice D, although related to safety, does not address the immediate risk of keeping oxygen tanks away from heat sources.

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