Nursing Elites

1. The nurse is developing a plan of care for a client who reports tingling in the feet and who is newly diagnosed with peripheral vascular disease. Which outcome should the nurse include in the plan of care for this client?

• A. The client will walk 30 minutes three times a week
• B. The client will demonstrate understanding of proper shoe fit
• C. The client will perform foot care daily
• D. The client's blood pressure readings will be less than 160/90 mmHg

Correct answer: D

Rationale: Controlling blood pressure is critical in managing peripheral vascular disease, as elevated pressure can exacerbate vascular damage and complications. While foot care, shoe fit, and exercise are important, lowering blood pressure is a primary goal. Proper blood pressure management helps in preventing further damage to the blood vessels and reduces the risk of complications associated with peripheral vascular disease, making it the most crucial outcome to include in the plan of care for this client.

2. The nurse prepares to teach clients about blood glucose monitoring. When should clients always check glucose, regardless of age or type of diabetes?

• A. Before going to bed.
• B. After meals.
• C. During acute illness.
• D. Prior to exercising.

Correct answer: C

Rationale: The correct answer is C: During acute illness. Checking blood glucose during acute illness is crucial as stress can elevate glucose levels. This monitoring is essential regardless of the client's age or the type of diabetes they have. Checking before going to bed (choice A) may be important for some individuals, but it's not as universally necessary as during acute illness. Checking after meals (choice B) and prior to exercising (choice D) are important times for monitoring blood glucose, but they are not as universally applicable as during acute illness.

3. After receiving a report on an inpatient acute care unit, which client should the nurse assess first?

• A. Client with pneumonia who has a fever of 101.5°F
• B. Client who underwent knee surgery and needs dressing change
• C. Client with a bowel obstruction due to a volvulus experiencing abdominal rigidity
• D. Client with diabetes requesting insulin

Correct answer: C

Rationale: The correct answer is C. Abdominal rigidity in a client with a bowel obstruction could indicate peritonitis, a serious complication requiring immediate attention. Volvulus, a twisting of the intestine, can lead to bowel ischemia and necrosis. Clients with pneumonia (choice A) may need assessment and treatment for infection, but it is not as immediately life-threatening as a bowel obstruction. A client who underwent knee surgery (choice B) needing a dressing change can typically wait for assessment compared to a potential surgical emergency. Similarly, a client with diabetes requesting insulin (choice D) may require attention to maintain blood glucose levels, but it is not as urgent as a suspected bowel obstruction with possible peritonitis.

4. The nurse is providing discharge teaching to a client with newly diagnosed hypertension. Which lifestyle modification should the nurse emphasize to the client?

• A. Increase sodium intake to improve fluid balance
• B. Engage in regular physical activity
• C. Increase caffeine intake to improve energy
• D. Reduce potassium intake to lower blood pressure

Correct answer: B

Rationale: Engaging in regular physical activity is a crucial lifestyle modification for managing hypertension. Regular exercise helps improve cardiovascular health, lower blood pressure, and contribute to overall well-being. Choices A, C, and D are incorrect. Increasing sodium intake is not recommended for hypertension as it can worsen fluid retention and elevate blood pressure. Increasing caffeine intake is also not advised as it may lead to increased heart rate and blood pressure. Reducing potassium intake is not beneficial as potassium is essential for maintaining healthy blood pressure levels.

5. A client with hyperparathyroidism is preparing for surgery. Which preoperative lab finding is most important to report?

• A. Elevated serum calcium.
• B. Decreased serum albumin.
• C. Elevated serum potassium.
• D. Elevated serum magnesium.

Correct answer: A

Rationale: The correct answer is A: Elevated serum calcium. In hyperparathyroidism, elevated calcium levels can lead to complications such as kidney stones, bone pain, and fractures. During surgery, high calcium levels can affect neuromuscular function, cardiac function, and blood clotting. Therefore, it is crucial to report elevated serum calcium levels preoperatively to prevent potential surgical complications. Choices B, C, and D are not directly associated with hyperparathyroidism and are less likely to impact the surgical outcome in this scenario.

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