Nursing Elites

1. After a myocardial infarction, why is the hospitalized client taught to move the legs while resting in bed?

• A. Prepare the client for ambulation.
• B. Promote urinary and intestinal elimination.
• C. Prevent thrombophlebitis and blood clot formation.
• D. Decrease the likelihood of pressure ulcer formation.

Correct answer: C

Rationale: The correct answer is C. Moving the legs helps prevent thrombophlebitis and blood clot formation by promoting venous return in clients on bed rest. This prevents stasis and clot formation in the lower extremities. Choices A, B, and D are incorrect because the primary goal of moving the legs is to prevent thrombophlebitis and blood clot formation, rather than preparing for ambulation, promoting elimination, or decreasing pressure ulcer formation. Ambulation preparation involves different exercises, urinary and intestinal elimination are not directly related to leg movements, and pressure ulcer prevention is more related to repositioning and skin care.

2. The nurse is administering intravenous fluids to a dehydrated patient. On the second day of care, the patient's weight has increased by 2.25 pounds. The nurse would expect that the patient's fluid intake has

• A. equaled urine output.
• B. exceeded urine output by 1 L.
• C. exceeded urine output by 2.5 L.
• D. exceeded urine output by 3 L.

Correct answer: B

Rationale: A weight gain of 1 kg, or approximately 2.2 to 2.5 lb, is generally equivalent to 1 liter (L) of fluid retained by the body. In this case, the patient's weight gain of 2.25 pounds suggests an excess fluid retention of approximately 1 liter, indicating that the patient's fluid intake has exceeded urine output by 1 liter. Choices C and D are incorrect as they overestimate the fluid excess based on the patient's weight gain. Choice A is incorrect as it implies an exact balance between fluid intake and urine output, which is not reflected in the given weight increase.

3. In a patient with type 1 diabetes, which of the following is a sign of diabetic ketoacidosis (DKA)?

• A. Polyuria
• B. Bradycardia
• C. Dry skin
• D. Tachycardia

Correct answer: D

Rationale: Tachycardia is a sign of diabetic ketoacidosis (DKA) in a patient with type 1 diabetes. In DKA, the body responds to hyperglycemia and dehydration by increasing heart rate. Polyuria (increased urination) is a symptom of diabetes but not specific to DKA. Bradycardia (slow heart rate) and dry skin are not typical signs of DKA; instead, tachycardia and other signs of volume depletion are more common.

4. Which instruction should be included in the discharge teaching plan for a client who underwent cataract extraction today?

• A. Use a metal eye shield on the operative eye during the day.
• B. Administer eye ointment before applying eye drops.
• C. Sexual activities may be resumed after returning home.
• D. Light housekeeping is safe to do, but avoid heavy lifting.

Correct answer: D

Rationale: The correct instruction to include in the discharge teaching plan for a client who underwent cataract extraction is to advise them that light housekeeping is safe to do, but they should avoid heavy lifting. Heavy lifting can strain the surgical site and potentially lead to complications. Choice A is incorrect as a metal eye shield is usually recommended during sleep, not during the day. Choice B is incorrect because eye ointment should typically be administered after applying eye drops to prevent dilution of the medication. Choice C is incorrect as sexual activities should usually be avoided for a specific period post-surgery as advised by the healthcare provider.

5. After teaching a client with renal cancer who is prescribed temsirolimus (Torisel), the nurse assesses the client’s understanding. Which statement made by the client indicates a correct understanding of the teaching?

• A. I will take this medication with food and plenty of water.
• B. I shall keep my appointment at the infusion center each week.
• C. I’ll limit my intake of green leafy vegetables while on this medication.
• D. I must not take this medication if I have an infection or am feeling ill.

Correct answer: B

Rationale: The correct answer is B. Temsirolimus, also known as Torisel, is administered as a weekly intravenous infusion. This medication blocks protein needed for cell division, inhibiting cell cycle progression. It is not taken orally, so there is no need to take it with food or water. Keeping the weekly infusion center appointment is crucial for the client to receive the prescribed treatment effectively. Choice A is incorrect as temsirolimus is not taken with food or water. Choice C is incorrect because there is no need to limit the intake of green leafy vegetables while on this medication. Choice D is incorrect as having an infection or feeling ill does not prohibit the use of temsirolimus.

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