Nursing Elites

1. The client with diabetes mellitus has gangrene of the toes to the midfoot. Which goal should be included in this client's plan of care?

• A. Restore skin integrity.
• B. Prevent infection.
• C. Promote healing.
• D. Improve nutrition.

Correct answer: B

Rationale: Preventing infection is crucial in clients with gangrene to halt the spread of infection and avert further complications. Infections can exacerbate tissue damage and lead to systemic complications, making infection prevention a priority in the care plan for this client. Restoring skin integrity and promoting healing may not be achievable goals until the infection is under control. Improving nutrition is important for overall health but may not be the priority when the immediate concern is preventing infection.

2. The client with myocardial infarction should reduce intake of saturated fat and cholesterol. Which food items from the dietary menu would assist the nurse in helping the client comply with diet therapy?

• A. Cheeseburger, pan-fried potatoes, whole kernel corn, sherbet
• B. Pork chop, baked potato, cauliflower in cheese sauce, ice cream
• C. Baked haddock, steamed broccoli, herbed rice, sliced strawberries
• D. Spaghetti and sweet sausage in tomato sauce, vanilla pudding (with 4% milk)

Correct answer: C

Rationale: Option C, which includes baked haddock, steamed broccoli, herbed rice, and sliced strawberries, is the most appropriate choice for a client with myocardial infarction looking to reduce saturated fat and cholesterol intake. This meal is low in saturated fats and cholesterol, making it a heart-healthy option that aligns with the dietary recommendations for such clients. Choices A, B, and D contain foods high in saturated fats and cholesterol, which are not suitable for a client with myocardial infarction trying to adhere to a diet therapy aimed at reducing these components.

3. A client has a new prescription for alendronate. Which of the following instructions should the nurse include?

• A. Take the medication with a full glass of water.
• B. Lie down for 30 minutes after taking the medication.
• C. Take the medication at bedtime.
• D. Avoid dairy products while taking the medication.

Correct answer: A

Rationale: When taking alendronate, it is important to take the medication with a full glass of water to prevent esophageal irritation. This helps ensure that the medication reaches the stomach and is properly absorbed. Lying down after taking alendronate can increase the risk of esophageal irritation, which is why it is recommended to stay upright for at least 30 minutes after taking the medication. Taking the medication at bedtime or avoiding dairy products are not specific instructions associated with alendronate administration. Therefore, the correct instruction to include is to take the medication with a full glass of water.

4. A client with a history of coronary artery disease (CAD) is prescribed simvastatin (Zocor). The nurse should teach the client about which potential side effect?

• A. Muscle pain
• B. Dry mouth
• C. Drowsiness
• D. Diarrhea

Correct answer: A

Rationale: Muscle pain is a common side effect of statins like simvastatin and can indicate a serious condition called rhabdomyolysis. Rhabdomyolysis is a severe condition where muscle fibers break down rapidly, releasing myoglobin into the bloodstream, which can lead to kidney damage. Therefore, it's important for the nurse to educate the client about this potential side effect and to promptly report any muscle pain to the healthcare provider. Dry mouth, drowsiness, and diarrhea are not commonly associated with simvastatin use and are less concerning compared to the risk of rhabdomyolysis.

5. A client is diagnosed with thrombophlebitis. The nurse should tell the client that which prescription is indicated?

• A. Bed rest, with bathroom privileges only
• B. Bed rest, keeping the affected extremity flat
• C. Bed rest, with elevation of the affected extremity
• D. Bed rest, with the affected extremity in a dependent position

Correct answer: C

Rationale: The correct answer is C: Bed rest, with elevation of the affected extremity. Elevating the affected extremity is crucial in managing thrombophlebitis as it helps reduce swelling and promotes venous return. By elevating the affected extremity, the gravitational force assists in venous blood flow back to the heart, thereby reducing the risk of complications associated with thrombophlebitis. Choices A, B, and D are incorrect because they do not address the need for elevation, which is specifically beneficial in the management of thrombophlebitis.

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