Nursing Elites

1. A client with newly diagnosed diabetes mellitus is receiving teaching on foot care. Which instruction should the nurse include?

• A. Walk barefoot whenever possible to toughen your feet.
• B. Soak your feet in hot water daily to improve circulation.
• C. Trim your toenails straight across to prevent ingrown toenails.
• D. Use a heating pad to keep your feet warm.

Correct answer: C

Rationale: Correctly trimming toenails straight across is crucial in preventing ingrown toenails and potential infections in individuals with diabetes. Ingrown toenails can lead to complications, so it is essential for diabetic clients to practice proper nail care to avoid these issues. Choices A, B, and D are incorrect. Walking barefoot can increase the risk of foot injuries, soaking feet in hot water can cause burns or skin damage, and using a heating pad can lead to burns or injuries due to decreased sensation in the feet, which is common in diabetes.

2. Why is a client with ascites scheduled for a paracentesis procedure?

• A. To diagnose liver disease
• B. To relieve abdominal pressure
• C. To assess kidney function
• D. To reduce blood pressure

Correct answer: B

Rationale: The correct answer is B: "To relieve abdominal pressure." Paracentesis is performed to drain accumulated fluid in the peritoneal cavity, providing symptomatic relief for clients with ascites. Choice A is incorrect because paracentesis is not a diagnostic procedure for liver disease. Choice C is incorrect as assessing kidney function would typically involve different procedures. Choice D is incorrect as paracentesis does not directly impact blood pressure.

3. A client with heart failure is receiving digoxin (Lanoxin). Which finding indicates that the medication is effective?

• A. Increased heart rate.
• B. Decreased pedal edema.
• C. Elevated blood pressure.
• D. Improved urine output.

Correct answer: B

Rationale: In a client with heart failure, decreased pedal edema is a positive indicator of improved cardiac output and reduced fluid retention. Digoxin works by increasing the strength of the heart's contractions, leading to improved circulation and reduced symptoms of heart failure, such as edema. Monitoring for decreased pedal edema is essential to assess the effectiveness of digoxin therapy. Choices A, C, and D are incorrect because an increased heart rate, elevated blood pressure, and improved urine output are not specific indicators of digoxin's effectiveness in managing heart failure. Instead, the focus should be on improvements related to fluid retention and cardiac function, like decreased pedal edema.

4. The community health nurse is working in a multi-ethnic health center. In what situation should the nurse intervene?

• A. An Asian-American mother reports using cupping to treat an infection, resulting in a pattern of red round marks on her toddler's back.
• B. A Hispanic pregnant client who is often late for appointments arrives late for today's appointment.
• C. A Native-American individual being interviewed will not make direct eye contact when asked about violence in the home.
• D. An African-American infant who is spitting up milk has lost 6 ounces since last week's clinic visit.

Correct answer: D

Rationale: The correct answer is D because losing weight in an infant, especially when combined with spitting up milk, requires immediate intervention to address potential health concerns. Choice A deals with a cultural practice that may not necessarily pose an immediate health risk. Choice B, while important, does not present an immediate health threat. Choice C relates to cultural differences in communication and does not necessarily indicate a need for immediate intervention in terms of health.

5. A patient with a diagnosis of deep vein thrombosis (DVT) is receiving heparin therapy. Which laboratory test should the nurse monitor to evaluate the effectiveness of the heparin therapy?

• A. Prothrombin time (PT)
• B. Partial thromboplastin time (PTT)
• C. Bleeding time
• D. Platelet count

Correct answer: B

Rationale: The correct answer is B: Partial thromboplastin time (PTT). Heparin affects the intrinsic pathway of the coagulation cascade, which is reflected by changes in the PTT. Monitoring the PTT helps ensure that the patient's blood is within the desired therapeutic range and prevents complications related to clotting or bleeding. Prothrombin time (PT) primarily assesses the extrinsic pathway and is not as sensitive to heparin therapy. Bleeding time and platelet count are not specific tests for monitoring the effectiveness of heparin therapy in DVT.

Similar Questions