Nursing Elites

1. The client with a diagnosis of hypertension is being taught about lifestyle changes. Which recommendation is most important to include?

• A. Increase sodium intake.
• B. Engage in regular physical activity.
• C. Avoid foods high in fat.
• D. Limit fluid intake to 1 liter per day.

Correct answer: B

Rationale: Engaging in regular physical activity is crucial for individuals with hypertension as it helps lower blood pressure and improve cardiovascular health. Physical activity is known to have a significant impact on reducing hypertension and overall cardiovascular risk. Choice A, increasing sodium intake, is incorrect as reducing sodium is typically recommended for hypertension to help lower blood pressure. Choice C, avoiding foods high in fat, is beneficial for overall health but not the most crucial recommendation for hypertension management. Choice D, limiting fluid intake to 1 liter per day, is not a standard recommendation for hypertension unless advised by a healthcare provider for specific cases. Therefore, the most important recommendation for the client with hypertension is to engage in regular physical activity.

2. A client is being treated for heart failure. What should the nurse monitor to evaluate treatment effectiveness?

• A. Daily weight
• B. Electrolyte levels
• C. Urine output
• D. All of the above

Correct answer: D

Rationale: Monitoring daily weight, electrolyte levels, and urine output is crucial in evaluating treatment effectiveness for heart failure. Daily weight monitoring helps assess fluid retention or loss, changes in electrolyte levels can indicate imbalances affecting heart function, and urine output monitoring provides insights into kidney function and fluid balance. Therefore, all options are essential components in assessing the patient's fluid status and response to treatment, making 'All of the above' the correct answer. Choices A, B, and C are incorrect individually as they only represent partial aspects of monitoring heart failure treatment effectiveness.

3. The nurse is assessing a client who has been receiving total parenteral nutrition (TPN) for several days. Which complication should the nurse monitor for?

• A. Hyperglycemia
• B. Hypoglycemia
• C. Hyponatremia
• D. Hypokalemia

Correct answer: B

Rationale: The correct answer is B: Hypoglycemia. When a client is receiving total parenteral nutrition (TPN) with a high glucose content, the risk of hypoglycemia is significant due to sudden increases in insulin release in response to the glucose load. The nurse should monitor for signs and symptoms of hypoglycemia such as shakiness, sweating, palpitations, and confusion. Hyperglycemia (choice A) is not typically a complication of TPN as the high glucose content is more likely to cause hypoglycemia. Hyponatremia (choice C) and hypokalemia (choice D) are electrolyte imbalances that can occur in clients receiving TPN, but hypoglycemia is the more common and immediate concern that the nurse should monitor for.

4. The nurse is caring for a client with a diagnosis of major depressive disorder who has been prescribed fluoxetine (Prozac). What is the most important teaching point?

• A. Take the medication with or without food.
• B. Report any increase in suicidal thoughts.
• C. Avoid foods high in tyramine.
• D. Expect improvement within 24 hours.

Correct answer: B

Rationale: The correct teaching point is to instruct the client to report any increase in suicidal thoughts. This is crucial because SSRIs like fluoxetine can initially increase suicidal ideation, especially at the beginning of treatment. Choice A is corrected to emphasize that fluoxetine can be taken with or without food. Choice C is unrelated as it pertains more to MAOIs than SSRIs like fluoxetine. Choice D is inaccurate as antidepressants like fluoxetine may take weeks to show significant improvement in symptoms, not within 24 hours.

5. During the shift change report at an acute care hospital, the charge nurse assigns the Licensed Practical Nurse (LPN) to care for a client. Which task is within the LPN's scope?

• A. Administering IV medication
• B. Conducting initial client assessments
• C. Providing wound care for a stage III pressure ulcer
• D. Teaching a diabetic client about insulin administration

Correct answer: C

Rationale: The correct answer is C. LPNs are trained to provide basic nursing care such as wound care. Providing wound care for a stage III pressure ulcer falls within the LPN's scope of practice. Administering IV medication (choice A) requires a higher level of skill and is usually the responsibility of registered nurses. Conducting initial client assessments (choice B) demands more advanced training and is typically performed by registered nurses. Teaching a diabetic client about insulin administration (choice D) involves patient education and is usually within the scope of registered nurses or other healthcare professionals with specific training in diabetic care.

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