Nursing Elites

1. The client is learning about lifestyle changes to manage hypertension. Which statement by the client requires further teaching?

• A. I will reduce my salt intake.
• B. I will exercise for 30 minutes most days of the week.
• C. I will drink alcohol only on the weekends.
• D. I will monitor my blood pressure regularly.

Correct answer: C

Rationale: The correct answer is C. Clients with hypertension should ideally avoid or limit alcohol intake rather than just restricting it to weekends. Excessive alcohol consumption can raise blood pressure and interfere with the effectiveness of hypertension management. Choices A, B, and D are all positive statements that align with managing hypertension: reducing salt intake, regular exercise, and monitoring blood pressure are all beneficial lifestyle changes for individuals with hypertension. Therefore, the statement about drinking alcohol only on weekends requires further teaching to emphasize the importance of reducing alcohol consumption for better blood pressure control.

2. A 54-year-old male client and his wife were informed this morning that he has terminal cancer. Which nursing intervention is likely to be most appropriate?

• A. Ask the wife how she would like to participate in the client's care
• B. Provide the wife with information about hospice
• C. Encourage the wife to visit during the treatment process
• D. Refer her to a support group for family members of those with terminal cancer

Correct answer: A

Rationale: In this situation, it is crucial to involve the wife in the care of the client to provide support and empower her. Asking the wife how she would like to participate allows her to be actively involved in decision-making and caregiving. Providing information about hospice (choice B) might be premature as the couple may still be digesting the diagnosis. Encouraging the wife to visit during the treatment process (choice C) may not address her immediate need for involvement and support. Referring her to a support group for family members (choice D) is helpful but involving her directly in the client's care is a more immediate and personalized approach.

3. When using an open irrigation technique to irrigate a client's indwelling urinary catheter, which of the following actions should the nurse take?

• A. Place the client in a side-lying position
• B. Instill 15 mL of irrigation fluid into the catheter with each flush
• C. Subtract the amount of irrigant used from the client's urine output
• D. Perform the irrigation using a 20 mL syringe

Correct answer: C

Rationale: The correct action for the nurse to take when using an open irrigation technique on a client with an indwelling urinary catheter is to subtract the amount of irrigant used from the client's urine output. This calculation helps ensure an accurate measurement of the client's actual urine output by accounting for the irrigation fluid introduced into the catheter. Placing the client in a side-lying position (Choice A) is not directly related to the irrigation procedure. Instilling a specific volume of irrigation fluid (Choice B) may vary depending on the client's condition and the healthcare provider's order. Using a 20 mL syringe for irrigation (Choice D) is a matter of equipment choice and does not directly impact the calculation of urine output in this context.

4. The nurse is caring for a client with a nasogastric (NG) tube. Which action should the nurse take to maintain patency of the tube?

• A. Flush the tube with 30 ml of water before and after medication administration.
• B. Administer the medication with food to prevent nausea.
• C. Verify tube placement by aspirating stomach contents.
• D. Dilute the medication with normal saline before administration.

Correct answer: A

Rationale: To maintain the patency of a nasogastric (NG) tube, it is essential to flush the tube with 30 ml of water before and after medication administration. This action helps ensure that the tube remains open and free from blockages. Flushing the tube prevents any medication residue from causing blockages, maintaining its patency. Choice B is incorrect because administering medication with food does not relate to maintaining tube patency. Choice C is incorrect as verifying tube placement by aspirating stomach contents is related to confirming correct tube placement, not maintaining patency. Choice D is also incorrect because diluting the medication with normal saline is not primarily aimed at maintaining the tube's patency.

5. A mother tells the nurse that her 2-year-old toddler has temper tantrums and says 'no' every time the mother tries to help them get dressed. The nurse should recognize the toddler is manifesting which of the following stages of development?

• A. Trying to increase independence.
• B. Developing a sense of trust.
• C. Establishing a new identity.
• D. Attempting to master a skill.

Correct answer: A

Rationale: The correct answer is A: Trying to increase independence. Toddlers around the age of 2 often exhibit behaviors like temper tantrums and saying 'no' as they are asserting their independence and autonomy. This behavior is a normal part of their developmental stage where they are starting to explore and assert their own preferences and desires. Choice B, developing a sense of trust, is more relevant to infants during the trust vs. mistrust stage. Choice C, establishing a new identity, is typically associated with adolescence and identity formation. Choice D, attempting to master a skill, is more indicative of a child trying to learn and develop new abilities rather than the behavior described in the scenario.

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