Nursing Elites

1. The nurse is teaching a client about lifestyle changes to manage hypertension. Which of the following should be emphasized?

• A. Increase daily intake of sodium.
• B. Exercise regularly and maintain a healthy weight.
• C. Reduce intake of potassium-rich foods.
• D. Drink alcohol in moderation.

Correct answer: B

Rationale: The correct answer is B. Regular exercise and maintaining a healthy weight are crucial lifestyle changes in managing hypertension. Exercise helps lower blood pressure and improves heart health, while maintaining a healthy weight reduces the risk of hypertension. Choices A, C, and D are incorrect. Increasing daily intake of sodium can elevate blood pressure, reducing intake of potassium-rich foods is not recommended as potassium helps lower blood pressure, and drinking alcohol should be limited or avoided as it can raise blood pressure.

2. The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high-protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective?

• A. A tuna fish sandwich with chips and ice cream
• B. A vegetable salad with croutons and ranch dressing
• C. A grilled chicken breast with steamed vegetables
• D. A peanut butter and jelly sandwich with soda

Correct answer: C

Rationale: The correct answer is C. Grilled chicken is an excellent source of protein, which is important for wound healing. Choices A, B, and D are less ideal for wound healing. Choice A contains high-fat and high-sugar components like chips and ice cream, which may not support wound healing effectively. Choice B includes croutons and ranch dressing, which may not provide as much protein as needed for wound healing. Choice D with a peanut butter and jelly sandwich and soda lacks a balanced meal with adequate protein to promote wound healing.

3. A client with a history of adrenal insufficiency is admitted with acute adrenal crisis. The client complains of nausea and joint pain, vital signs show a temperature of 102°F, heart rate of 138, and blood pressure of 80/60. Which intervention should the nurse implement first?

• A. Obtain an analgesic prescription.
• B. Infuse an intravenous fluid bolus.
• C. Administer PRN oral antipyretic.
• D. Cover the client with a cooling blanket.

Correct answer: B

Rationale: In acute adrenal crisis, the priority intervention is to infuse an intravenous fluid bolus to address the hypotension (blood pressure of 80/60) and help stabilize the client's condition. Adequate fluid volume is crucial in managing adrenal insufficiency crisis. Options A, C, and D do not directly address the hypotension and fluid volume depletion that are critical in this situation. Analgesics, antipyretics, and cooling blankets may be considered later, but the immediate focus should be on fluid resuscitation.

4. A client with heart failure is prescribed digoxin and reports nausea. What is the nurse's first action?

• A. Administer an anti-nausea medication as prescribed.
• B. Assess the client's digoxin level immediately.
• C. Assess the client’s apical pulse and hold the next dose if it's below 60 bpm.
• D. Instruct the client to reduce their fluid intake.

Correct answer: B

Rationale: When a client on digoxin reports nausea, it can be a sign of digoxin toxicity. The priority action for the nurse is to assess the client's digoxin level immediately. This assessment will help determine if the nausea is related to digoxin toxicity, requiring a dosage adjustment. Administering an anti-nausea medication (Choice A) does not address the underlying issue of potential digoxin toxicity. Assessing the client's apical pulse (Choice C) is important in general digoxin monitoring but not the first action when nausea is reported. Instructing the client to reduce fluid intake (Choice D) is not the initial response to nausea in a client taking digoxin.

5. A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Which of the following should take priority in planning care?

• A. Esophagitis
• B. Leukopenia
• C. Fatigue
• D. Skin irritation

Correct answer: B

Rationale: The correct answer is B: Leukopenia. Leukopenia, or a low white blood cell count, is a critical concern in clients undergoing radiation therapy due to the increased risk of infection. While esophagitis, fatigue, and skin irritation are also potential side effects of radiation therapy, leukopenia poses a higher risk as it compromises the body's ability to fight infections effectively.

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