Nursing Elites

1. During a home visit, the nurse finds that an elderly client has multiple expired medications. What should the nurse do first?

• A. instruct the client to dispose of the expired medications
• B. review the client's current medication regimen
• C. contact the client's healthcare provider
• D. educate the client on the dangers of taking expired medications

Correct answer: B

Rationale: The correct first action for the nurse to take when finding multiple expired medications in an elderly client's home is to review the client's current medication regimen. This step is crucial to identify any potential issues, ensure the client is taking the correct medications, and understand why the expired medications were not used. Instructing the client to dispose of the expired medications (Choice A) can come after understanding the current medication situation. Contacting the client's healthcare provider (Choice C) may be necessary but reviewing the medication regimen should be the initial step. Educating the client on the dangers of taking expired medications (Choice D) is important but should be done after addressing the immediate concern of reviewing the current medications.

2. A client with a history of hypertension is prescribed enalapril (Vasotec). Which statement by the client indicates a need for further teaching?

• A. I will monitor my blood pressure regularly.
• B. I will report any signs of infection to my healthcare provider.
• C. I will avoid using salt substitutes.
• D. I will increase my intake of potassium-rich foods.

Correct answer: D

Rationale: The correct answer is D. Increasing potassium intake can lead to hyperkalemia, especially in clients taking ACE inhibitors like enalapril. Hyperkalemia is a potential side effect of ACE inhibitors and can be exacerbated by consuming potassium-rich foods. Monitoring blood pressure regularly (A) is important when taking antihypertensive medications. Reporting signs of infection (B) is crucial as ACE inhibitors can lower the immune response. Avoiding salt substitutes (C) is necessary because they may contain potassium chloride, leading to increased potassium levels, which can be harmful in combination with ACE inhibitors.

3. The healthcare professional is providing education on healthy eating habits to a group of adolescents. Which strategy is most likely to be effective?

• A. lecturing about the dangers of unhealthy eating
• B. distributing pamphlets on healthy food choices
• C. involving the adolescents in meal planning and preparation
• D. showing a documentary on the benefits of a healthy diet

Correct answer: C

Rationale: Involving adolescents in meal planning and preparation is a more effective strategy as it actively engages them in the learning process. This approach allows adolescents to have hands-on experience, make informed choices, and develop a sense of ownership over their dietary decisions. Lecturing about dangers or showing documentaries may not be as engaging or interactive, making it less likely for adolescents to retain and apply the information provided. Distributing pamphlets can be informative but lacks the interactive and experiential aspect that involving them in meal planning and preparation offers.

4. In conducting a health assessment for a family with a history of diabetes, which family member should be prioritized for further evaluation and intervention?

• A. a 50-year-old mother with a history of hypertension
• B. a 45-year-old father who is overweight and has high cholesterol
• C. a 17-year-old daughter who is inactive
• D. a 12-year-old son who has a normal weight and is active

Correct answer: B

Rationale: The correct answer is the 45-year-old father who is overweight and has high cholesterol. He possesses multiple risk factors for diabetes, indicating a need for prioritized evaluation and intervention. The mother's hypertension, the daughter's inactivity, and the son's normal weight and activity level are important factors to consider but do not present as immediate red flags for diabetes risk compared to the father's combination of being overweight and having high cholesterol.

5. The home health nurse visits a young male client with AIDS who has Kaposi's sarcoma and peripheral neuropathies. His parents, who are the caregivers, tell the nurse that their son sleeps most of the time. The nurse assesses that the client is semi-conscious with stable vital signs, cries out in pain when turned or moved, has a Duragesic pain patch in place, and skin lesions that are closed and dried. Which intervention should the nurse implement?

• A. remove the Duragesic patch as directed by the prescription
• B. give the client a complete bed bath to further assess the client's condition
• C. discuss end-of-life decisions with the client's parents
• D. call for ambulance transportation to the hospital immediately

Correct answer: C

Rationale: In this scenario, the client with AIDS is showing signs of being in a critical condition - semi-conscious, in pain, and with stable vital signs. The appropriate intervention for the nurse to implement is to discuss end-of-life decisions with the client's parents. Given the client's symptoms, the presence of a pain patch, and the closed and dried skin lesions, it is essential to address end-of-life care planning. Removing the Duragesic patch without proper authorization can lead to inadequate pain management and should not be done without consulting the healthcare provider. Giving a complete bed bath is not the priority in this situation as it does not address the immediate needs of the client. Calling for ambulance transportation to the hospital immediately may not be necessary if the client is stable; instead, the focus should be on providing appropriate support and having critical discussions about the client's care preferences.

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