Nursing Elites

1. The healthcare provider is teaching a client with hypertension about lifestyle modifications. Which instruction should the healthcare provider include?

• A. Limit sodium intake to 2,300 mg per day
• B. Engage in moderate exercise for 30 minutes daily
• C. Consume a diet high in saturated fats
• D. Avoid alcohol consumption completely

Correct answer: B

Rationale: Engaging in moderate exercise for 30 minutes daily is a crucial lifestyle modification for managing hypertension. Regular physical activity helps lower blood pressure, improve cardiovascular health, and overall well-being. It is recommended to engage in activities like brisk walking, cycling, or swimming to achieve these benefits. Choices A, C, and D are incorrect. Limiting sodium intake, avoiding a diet high in saturated fats, and reducing alcohol consumption are also important lifestyle modifications for hypertension management, but engaging in moderate exercise is the most appropriate initial instruction for this client.

2. The client has a chest tube. What is the most important action for the nurse to take?

• A. Ensure the chest tube remains unclamped at all times.
• B. Empty the chest tube every 2 hours.
• C. Keep the drainage system below the level of the chest.
• D. Assess for subcutaneous emphysema.

Correct answer: C

Rationale: Keeping the drainage system below the level of the chest (C) is crucial to ensure proper drainage and prevent backflow of air or fluid into the chest cavity. This position helps maintain the integrity of the closed drainage system. Ensuring the chest tube remains unclamped at all times (A) allows for continuous drainage. Emptying the chest tube (B) should be done as needed, not routinely every 2 hours. Assessing for subcutaneous emphysema (D) is important but not the most critical action in this scenario.

3. The client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy. Which intervention should the nurse implement to ensure the client’s safety?

• A. Encourage the client to use oxygen continuously
• B. Monitor the client’s respiratory rate and effort
• C. Set the oxygen flow rate at 6 liters per minute
• D. Teach the client to avoid wearing wool blankets

Correct answer: B

Rationale: Monitoring the client’s respiratory rate and effort is essential to evaluate the effectiveness of oxygen therapy and prevent complications such as respiratory depression. This intervention helps the nurse promptly detect any deterioration in the client's respiratory status and take necessary actions to ensure the client's safety. Encouraging continuous oxygen use (Choice A) may lead to oxygen toxicity. Setting the oxygen flow rate at a specific level (Choice C) without individual assessment can be inappropriate and potentially harmful. Teaching the client to avoid wearing wool blankets (Choice D) is unrelated to the safe use of oxygen therapy.

4. After receiving written and verbal instructions from a clinic nurse about a newly prescribed medication, a client asks the nurse what to do if questions arise about the medication after getting home. How should the nurse respond?

• A. Provide the client with a list of reputable Internet sites that answer frequently asked questions about medications.
• B. Advise the client to obtain a current edition of a drug reference book from a local bookstore or library.
• C. Reassure the client that information about the medication is included in the written instructions.
• D. Encourage the client to call the clinic nurse or health care provider if any questions arise.

Correct answer: D

Rationale: To ensure safe medication use, the nurse should encourage the client to call the clinic nurse or health care provider if any questions arise. Direct communication with healthcare professionals involved in the client's care is crucial to address any concerns promptly and accurately, ensuring the client's safety and understanding of the prescribed medication.

5. When a health care provider diagnoses metastatic cancer and recommends a gastrostomy for an older female client in stable condition, the son tells the nurse that his mother must not be told the reason for the surgery because she 'can't handle' the cancer diagnosis. Which legal principle is the court most likely to uphold regarding this client's right to informed consent?

• A. The family cannot provide the consent required in this situation because the older adult is in a condition to make such decisions.
• B. Because the client is mentally incompetent, the son does not have the right to waive informed consent for her.
• C. The court will not allow the health care provider to make the decision to withhold informed consent under therapeutic privilege.
• D. If informed consent is withheld from a client, health care providers could be found guilty of negligence.

Correct answer: D

Rationale: In the scenario described, it is crucial for health care providers to obtain informed consent from the client before proceeding with any medical intervention. If informed consent is withheld and the treatment is carried out without the client's agreement, health care providers could be found guilty of negligence, specifically assault and battery. This legal principle emphasizes the importance of respecting a client's autonomy and right to make decisions about their own healthcare. Despite the son's wishes to withhold information from his mother, the client must be informed of the proposed treatment and given the opportunity to consent or refuse based on complete information provided by the healthcare team.

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