Nursing Elites

1. A client who is to undergo an exercise stress test is being taught by a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should eat a large meal 2 hours before the test
• B. I should avoid drinking water before the test
• C. I should stop taking my blood pressure medication
• D. I should report any chest pain during the test

Correct answer: D

Rationale: The correct answer is D: 'I should report any chest pain during the test.' This statement indicates an understanding of the teaching because reporting chest pain during an exercise stress test is crucial as it may signify cardiac distress. Choices A, B, and C are incorrect. Eating a large meal 2 hours before the test is not recommended as it may affect the results. Avoiding drinking water before the test is also not advisable as staying hydrated is important. Stopping blood pressure medication without medical advice can be dangerous, especially before a stress test.

2. What are key signs of fluid overload?

• A. Edema
• B. Hypertension
• C. Shortness of breath
• D. All of the above

Correct answer: D

Rationale: The correct answer is 'D: All of the above.' Edema, hypertension, and shortness of breath are key signs of fluid overload, particularly common in patients with heart failure. Edema refers to the swelling caused by excess fluid trapped in the body's tissues, hypertension can be a result of fluid volume overload, and shortness of breath can occur due to fluid accumulation in the lungs. Therefore, all these signs collectively indicate fluid overload in a patient. Choices A, B, and C are incorrect individually as each alone may not necessarily indicate fluid overload, but when seen together, they strongly suggest fluid volume excess in the body.

3. 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.

4. What is the best nursing intervention for a patient with hyperkalemia?

• A. Administer potassium-wasting diuretics
• B. Encourage a low-potassium diet
• C. Administer potassium supplements
• D. Administer IV fluids

Correct answer: A

Rationale: The correct answer is to administer potassium-wasting diuretics. Hyperkalemia, which is high potassium levels, is managed by promoting the excretion of potassium from the body. Potassium-wasting diuretics help the kidneys eliminate excess potassium. Encouraging a low-potassium diet (choice B) is important for long-term management but not the immediate intervention for hyperkalemia. Administering potassium supplements (choice C) would worsen the condition by further increasing potassium levels. Administering IV fluids (choice D) may help with hydration but does not directly address the high potassium levels characteristic of hyperkalemia.

5. What are the signs and symptoms of fluid overload, and how should a nurse manage this condition?

• A. Edema, weight gain, shortness of breath
• B. Fever, cough, chest pain
• C. Increased heart rate, low blood pressure
• D. Increased blood pressure, jugular venous distention

Correct answer: A

Rationale: Fluid overload manifests as edema, weight gain, and shortness of breath. These symptoms occur due to an excess of fluid in the body. Managing fluid overload involves interventions such as monitoring fluid intake and output, adjusting diuretic therapy, restricting fluid intake, and collaborating with healthcare providers to address the underlying cause. Choices B, C, and D are incorrect because they do not represent typical signs of fluid overload. Fever, cough, chest pain, increased heart rate, low blood pressure, increased blood pressure, and jugular venous distention are not primary indicators of fluid overload.

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