Nursing Elites

1. The nurse prepares a discharge plan for an older adult client following cataract extraction. What instructions should the nurse provide?

• A. Avoid straining, bending, or lifting heavy objects.
• B. Limit exposure to sunlight for the first 2 weeks.
• C. Irrigate the conjunctiva with saline before applying ointment.
• D. Read without direct lighting for 6 weeks.

Correct answer: A

Rationale: The correct instruction for the nurse to provide after cataract extraction is to advise the client to avoid straining, bending, or lifting heavy objects. These activities can increase intraocular pressure, which should be minimized post-surgery to promote healing and prevent complications. Choices B, C, and D are incorrect because limiting sunlight exposure, irrigating the conjunctiva with saline, and reading without direct lighting are not primary instructions following cataract extraction.

2. The nurse is providing discharge teaching to a client with asthma. Which statement indicates the client understands how to use a rescue inhaler?

• A. I will use my rescue inhaler every morning to prevent asthma attacks.
• B. I should use my rescue inhaler when I start to experience wheezing.
• C. I will use my rescue inhaler when my peak flow meter reading is in the green zone.
• D. I will only use my rescue inhaler before going to bed.

Correct answer: B

Rationale: The correct answer is B: 'I should use my rescue inhaler when I start to experience wheezing.' A rescue inhaler is used during the onset of asthma symptoms, such as wheezing, to quickly open the airways. It is not intended for routine daily use or prevention, which is the role of a maintenance inhaler. Option A is incorrect because a rescue inhaler is not used for prevention but for immediate relief during an asthma attack. Option C is incorrect because the peak flow meter reading is used to monitor asthma control, not to determine when to use a rescue inhaler. Option D is incorrect because using a rescue inhaler only before going to bed does not address the need for immediate relief when wheezing or experiencing asthma symptoms.

3. What are the primary pathophysiological mechanisms responsible for ascites in liver failure?

• A. Decreased liver enzymes.
• B. Increased hydrostatic pressure in portal circulation.
• C. High bilirubin levels.
• D. Fluid shifts due to decreased serum proteins.

Correct answer: B

Rationale: The correct answer is B: Increased hydrostatic pressure in portal circulation. Ascites in liver failure is primarily caused by fluid shifts from the intravascular space to the interstitial space due to increased hydrostatic pressure in the portal circulation. Choice A is incorrect as ascites is not caused by decreased liver enzymes. Choice C is incorrect as high bilirubin levels are not the primary mechanism for ascites in liver failure. Choice D is incorrect as fluid shifts in ascites are due to decreased serum proteins, not increased serum proteins.

4. A client is being discharged following a cystectomy and urinary diversion. What is the most important instruction for the nurse to provide?

• A. Avoid lifting heavy objects for six weeks.
• B. Report any signs of cloudy urine output.
• C. Drink 8 glasses of water a day.
• D. Monitor for signs of infection at the surgical site.

Correct answer: B

Rationale: The most important instruction for the nurse to provide to a client following a cystectomy and urinary diversion is to report any signs of cloudy urine output. Cloudy urine may indicate infection, which is a serious concern in clients with a urinary diversion. Instructing the client to report any signs of infection immediately is crucial to prevent complications. Avoiding heavy lifting is important for postoperative recovery but not as critical as identifying a potential infection. Drinking an adequate amount of water is generally beneficial for health but not the most crucial instruction in this scenario. While monitoring for signs of infection at the surgical site is essential, cloudy urine is a more specific and immediate indicator of a potential problem in clients with urinary diversions.

5. A client with hypertension has been prescribed a calcium channel blocker. What should the nurse include in the client's teaching plan?

• A. Monitor heart rate regularly
• B. Avoid potassium-rich foods
• C. Increase fluid intake to avoid dehydration
• D. Take the medication with food

Correct answer: A

Rationale: Corrected Rationale: Calcium channel blockers can cause bradycardia, so it is important for the client to monitor their heart rate regularly. This helps detect any significant changes in heart rate that may require medical attention. Choice B is incorrect because there is no need to avoid potassium-rich foods with calcium channel blockers. Choice C is incorrect as increasing fluid intake is not specifically related to calcium channel blockers. Choice D is incorrect as calcium channel blockers are usually taken with or without food, depending on the specific medication, but not specifically on an empty stomach.

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