Nursing Elites

1. The client is receiving discharge teaching for heart failure. Which statement made by the client indicates a need for further teaching?

• A. I will weigh myself daily and report any significant weight gain to my healthcare provider.
• B. I will limit my sodium intake to help manage my heart failure.
• C. I will take my medications as prescribed by my healthcare provider.
• D. I will stop taking my medications if I feel better.

Correct answer: D

Rationale: Choice D is the correct answer because stopping medications when feeling better can be harmful in heart failure. It is essential to complete the full course of medication as prescribed by the healthcare provider to effectively manage heart failure. Choices A, B, and C demonstrate good understanding and compliance with heart failure management strategies, such as monitoring weight, restricting sodium intake, and adhering to prescribed medications, respectively.

2. The nurse is caring for a client who requires a mechanical ventilator for breathing. The high-pressure alarm goes off on the ventilator. What is the first action the nurse should perform?

• A. Disconnect the client from the ventilator and use a manual resuscitation bag
• B. Perform a quick assessment of the client's condition
• C. Call the respiratory therapist for help
• D. Press the alarm reset button on the ventilator

Correct answer: B

Rationale: When the high-pressure alarm on a ventilator goes off, the nurse's initial action should be to perform a quick assessment of the client's condition. This assessment helps in promptly identifying the cause of the alarm, such as mucus plugging, kinking of the tubing, or other issues. By assessing the client first, the nurse can determine the appropriate intervention needed to address the alarm. Choices A and D are incorrect because disconnecting the client from the ventilator or pressing the alarm reset button should not be the initial actions without assessing the client's condition. While calling the respiratory therapist for help could be beneficial, assessing the client's condition should be the nurse's priority to address the immediate concern.

3. A client who had a vasectomy is in the post-recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse?

• A. Until the healthcare provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception.
• B. This procedure doesn't impede the production of male hormones or the production of sperm in the testicles. The sperm can no longer enter your semen, and no sperm are in your ejaculate.
• C. After your vasectomy, strenuous activity needs to be avoided for at least 48 hours. If your work doesn't involve hard physical labor, you can return to your job as soon as you feel up to it. The stitches generally dissolve in seven to ten days.
• D. The healthcare provider at this clinic recommends rest, ice, an athletic supporter, or over-the-counter pain medication to relieve any discomfort.

Correct answer: A

Rationale: The most crucial point to reinforce to the patient after a vasectomy is the need for continued contraception until it is confirmed that the ejaculate is sperm-free. Choice A emphasizes this by highlighting the importance of using another form of contraception until the healthcare provider confirms the absence of sperm. This is essential to prevent unintended pregnancies. Choices B, C, and D do not address the key point of ensuring contraception until sperm absence is confirmed and are therefore not as important to reinforce in this scenario.

4. During a physical assessment on a client who just had an endotracheal tube inserted, which finding would call for immediate action by the nurse?

• A. Breath sounds are auscultated bilaterally
• B. Mist is visible in the T-Piece
• C. Pulse oximetry of 88%
• D. Client is unable to speak

Correct answer: C

Rationale: A pulse oximetry reading of 88% indicates hypoxemia, which requires immediate intervention to ensure adequate oxygenation. In this scenario, the priority is to address the low oxygen saturation to prevent further complications. Auscultation of bilateral breath sounds is a positive finding as it indicates air entry into both lungs. Mist in the T-piece is expected in clients with an endotracheal tube, and the inability to speak is common due to the tube's placement.

5. The client is being taught about precautions with Coumadin therapy. Which over-the-counter medication should the client be instructed to avoid?

• A. Non-steroidal anti-inflammatory drugs
• B. Cough medicines with guaifenesin
• C. Histamine blockers
• D. Laxatives containing magnesium salts

Correct answer: A

Rationale: The correct answer is A: Non-steroidal anti-inflammatory drugs (NSAIDs). When a client is on Coumadin therapy, NSAIDs should be avoided because they can increase the risk of bleeding due to their antiplatelet effects. Choices B, C, and D are incorrect. Cough medicines with guaifenesin, histamine blockers, and laxatives containing magnesium salts do not have a significant interaction with Coumadin therapy that would necessitate avoidance.

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