Nursing Elites

1. The nurse is managing the care of a client with Cushing's syndrome. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply)

• A. Evaluate the client for sleep disturbances
• B. limit client exercise
• C. Report any client complaint of pain or discomfort
• D. Note and report the client's food and liquid intake during meals and snacks

Correct answer: D

Rationale: Weighing the client and monitoring food and liquid intake are appropriate tasks to delegate to the unlicensed assistive personnel (UAP) when managing a client with Cushing's syndrome. These tasks provide essential information for evaluating the client's condition and response to treatment. Evaluating for sleep disturbances and reporting client complaints of pain or discomfort require a higher level of assessment and interpretation, which should be performed by licensed healthcare providers. Therefore, options A and C are tasks that involve assessment and interpretation beyond the scope of practice for UAP.

2. Which medication should the nurse anticipate administering to a client who is diagnosed with myxedema coma?

• A. Intravenous administration of thyroid hormones
• B. Oral administration of hypnotic agents
• C. Intravenous bolus of hydrocortisone
• D. Subcutaneous administration of vitamin K

Correct answer: A

Rationale: The correct answer is A: Intravenous administration of thyroid hormones. Myxedema coma is a severe form of hypothyroidism that necessitates immediate replacement of thyroid hormones. Administering thyroid hormones intravenously ensures rapid absorption and effectiveness in managing the condition. Choice B, oral administration of hypnotic agents, is incorrect as it does not address the primary issue of thyroid hormone deficiency in myxedema coma. Choice C, intravenous bolus of hydrocortisone, is not the appropriate treatment for myxedema coma as adrenal insufficiency is not the primary concern in this condition. Choice D, subcutaneous administration of vitamin K, is unrelated to the management of myxedema coma and does not address the underlying thyroid hormone deficiency that characterizes this condition.

3. A male client with angina pectoris is being discharged from the hospital. What instructions should the nurse plan to include in the discharge teaching?

• A. Engage in physical exercise before eating to help decrease cholesterol levels.
• B. Avoid walking briskly in cold weather to prevent a decrease in cardiac output.
• C. Keep nitroglycerin in a light-colored plastic bottle and readily available.
• D. Avoid all isometric exercises, but walk regularly.

Correct answer: C

Rationale: The correct answer is to keep nitroglycerin in a light-colored container and readily available. Nitroglycerin should be protected from light to maintain its effectiveness. Option A is incorrect because physical exercise immediately before eating can trigger angina. Option B is incorrect as cold weather can exacerbate angina symptoms. Option D is incorrect as isometric exercises can increase the workload on the heart, which is not recommended for individuals with angina.

4. In a client in her third trimester of pregnancy, an S3 heart sound is auscultated. What intervention should the nurse take?

• A. Notify the healthcare provider
• B. Limit the client’s fluids
• C. Prepare the client for an echocardiogram
• D. Document in the client’s record

Correct answer: D

Rationale: An S3 heart sound can be a normal finding in pregnancy due to increased blood volume and flow. In this scenario, there is no immediate need for further interventions. Documenting this finding in the client's record is essential for tracking the client's health status and ensuring proper follow-up if needed. Notifying the healthcare provider, limiting fluids, or preparing for an echocardiogram is unnecessary as it is likely a physiological finding in pregnancy. These interventions should only be considered if other symptoms suggestive of a cardiac issue are present.

5. A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing and the tape securing the intravenous (IV) line. The abdominal dressing is no longer occlusive, and the IV insertion site is pink. What intervention should the nurse implement?

• A. Replace the IV site with a smaller gauge.
• B. Redress the abdominal incision.
• C. Leave the lights on in the room at night.
• D. Apply soft bilateral wrist restraints.

Correct answer: C

Rationale: The correct intervention for a client with dementia who is becoming increasingly confused at night and interfering with dressings and IV lines is to leave the lights on in the room at night. This intervention can help reduce confusion and disorientation. Choice A is incorrect because changing the IV site gauge is not the priority in this situation. Choice B is not necessary unless there are signs of infection or other complications at the abdominal incision site, which are not mentioned in the scenario. Choice D should be avoided as using restraints should be a last resort and is not indicated in this case.

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