Nursing Elites

1. The nurse is teaching a client with hypertension about lifestyle modifications. Which recommendation is most effective for lowering blood pressure?

• A. Increase intake of red meat
• B. Engage in regular physical activity
• C. Consume a high-sodium diet
• D. Limit fluid intake to 1 liter per day

Correct answer: B

Rationale: Engaging in regular physical activity is a highly effective recommendation for lowering blood pressure and improving overall cardiovascular health. Regular exercise helps to strengthen the heart, improve blood circulation, and manage weight, all of which contribute to reducing blood pressure levels. Choices A, C, and D are incorrect. Increasing intake of red meat can lead to higher saturated fat consumption, which is detrimental to heart health. Consuming a high-sodium diet can exacerbate hypertension by increasing blood pressure. Limiting fluid intake to 1 liter per day may lead to dehydration and is not a recommended approach for managing hypertension.

2. The nurse is assessing an older resident with a history of Benign Prostatic Hypertrophy and identifies a distended bladder. What should the nurse do?

• A. Stand the client to void and run tap water within hearing distance before catheterizing
• B. Straight catheterize and if the residual urine volume is greater than 100 mL, clamp catheter
• C. Catheterize q2h and place in an indwelling catheter at the end of the prescribed 24hr period
• D. Catheterize with an indwelling catheter and if the residual volume is greater than 100 mL, inflate the balloon

Correct answer: D

Rationale: Prompt and appropriate management of urinary retention prevents complications like infection and bladder damage.

3. A client with a diagnosis of pneumonia is experiencing difficulty expectorating thick secretions. What intervention should the nurse implement to assist the client?

• A. Administer antibiotics as prescribed.
• B. Encourage increased fluid intake.
• C. Perform chest physiotherapy.
• D. Provide humidified oxygen.

Correct answer: B

Rationale: Encouraging increased fluid intake is the appropriate intervention to assist the client with pneumonia who is having difficulty expectorating thick secretions. Adequate hydration helps to thin the secretions, making them easier to cough up. Administering antibiotics (Choice A) is important for treating the infection itself but does not directly address the thick secretions. Chest physiotherapy (Choice C) may be beneficial in some cases but is not the initial intervention for thick secretions. Providing humidified oxygen (Choice D) can help with oxygenation but does not directly address the problem of thick secretions.

4. The nurse is caring for a client with Myasthenia Gravis. What time of day is best for the nurse to schedule physical exercises with the physical therapy department?

• A. Before bedtime, at 2000
• B. After breakfast
• C. Before the evening meal
• D. After lunch

Correct answer: B

Rationale: Scheduling physical exercises after breakfast is the optimal choice for a client with Myasthenia Gravis. This timing allows the client to benefit from renewed energy levels after overnight rest and intake of morning nourishment, enhancing the effectiveness of the therapy session. Choices A (Before bedtime, at 2000) is not suitable as energy levels are likely lower at night, affecting the client's ability to engage effectively in physical exercises. Choices C (Before the evening meal) and D (After lunch) may not be ideal as the client may experience fatigue or weakness later in the day, making it harder to participate actively in therapy.

5. A client with chronic obstructive pulmonary disease (COPD) is struggling to breathe. What should the nurse do first?

• A. Increase the oxygen flow rate according to the prescription
• B. Encourage the client to perform pursed-lip breathing
• C. Prepare for emergency intubation
• D. Assess the client's oxygen saturation and breath sounds

Correct answer: D

Rationale: The correct first action for a nurse when a client with COPD is struggling to breathe is to assess the client's oxygen saturation and breath sounds. This initial assessment is crucial in determining the severity of the client's condition and the appropriate intervention. Increasing the oxygen flow rate without proper assessment can potentially be harmful, as COPD clients have a risk of retaining carbon dioxide. Encouraging pursed-lip breathing can be beneficial but should come after assessing the client's current status. Emergency intubation is a drastic measure and should only be considered after a comprehensive assessment indicates the need for it.

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