Nursing Elites

1. The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective?

• A. If I exercise at least two times weekly for one hour, I will lower my cholesterol.
• B. I need to avoid eating proteins, including red meat.
• C. I will limit my intake of beef to 4 ounces per week.
• D. My blood level of low density lipoproteins needs to increase.

Correct answer: C

Rationale: Limiting saturated fat from animal food sources to no more than 4 ounces per week is an important diet modification for lowering cholesterol. To be effective in reducing cholesterol, the client should exercise 30 minutes per day, or at least 4 to 6 times per week. Red meat and all proteins do not need to be eliminated to lower cholesterol, but should be restricted to lean cuts of red meat and smaller portions. The low density lipoproteins need to decrease rather than increase.

2. A client who has been on bed rest for several days is at risk for developing deep vein thrombosis (DVT). Which intervention should the nurse include in the client's plan of care?

• A. Encourage the client to ambulate as tolerated.
• B. Apply antiembolism stockings as prescribed.
• C. Elevate the client's legs on a pillow.
• D. Perform passive range-of-motion exercises daily.

Correct answer: B

Rationale: Applying antiembolism stockings as prescribed (B) is an effective intervention to prevent deep vein thrombosis (DVT) in a client on bed rest. While encouraging ambulation (A), elevating the legs (C), and performing passive range-of-motion exercises (D) are also beneficial, compression stockings are particularly effective in reducing the risk of DVT by promoting venous return and reducing stasis in the lower extremities.

3. A client is diagnosed with primary hypertension. Which assessment finding is most commonly associated with this diagnosis?

• A. Headache
• B. Dizziness
• C. Fatigue
• D. Edema

Correct answer: A

Rationale: Headache (A) is the most commonly associated symptom with primary hypertension due to increased pressure in the blood vessels, leading to headaches. While dizziness (B), fatigue (C), and edema (D) may also occur in hypertension, headache is the most frequently reported symptom among individuals with primary hypertension.

4. During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often awake until midnight playing and is then very difficult to awaken in the morning for school. Which assessment data should the nurse obtain in response to the mother's report?

• A. The occurrence of any episodes of sleep apnea
• B. The child's blood pressure, pulse, and respirations
• C. Length of rapid eye movement (REM) sleep that the child is experiencing
• D. Description of the family's home environment

Correct answer: D

Rationale: In response to the mother's report, the nurse should assess the family's home environment first to identify any factors that may hinder the establishment of bedtime routines conducive to sleep. Factors such as noise, light, distractions, or other environmental aspects could be contributing to the child's difficulty falling asleep at a reasonable hour and waking up in the morning.

5. The nurse is completing a client's preoperative routine and finds that the operative permit is not signed. The client begins to ask more questions about the surgical procedure. Which action should the nurse take next?

• A. Witness the client's signature on the permit.
• B. Answer the client's questions about the surgery.
• C. Inform the surgeon that the operative permit is not signed and the client has questions about the surgery.
• D. Reassure the client that the surgeon will answer any questions before the anesthesia is administered.

Correct answer: C

Rationale: The nurse should inform the surgeon immediately that the operative permit is not signed and that the client has questions about the surgery. It is crucial for the surgeon to be aware of the situation so they can address the client's concerns, explain the procedure, and obtain the necessary signed permit before proceeding with the surgery. This ensures informed consent and compliance with preoperative protocols.

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