Nursing Elites

1. A client is prescribed lisinopril (Zestril) for the treatment of hypertension. He asks the nurse about possible adverse effects. The nurse should inform him about which common adverse effects of angiotensin-converting enzyme (ACE) inhibitors?

• A. Constipation
• B. Dizziness
• C. Headache
• D. B, C

Correct answer: D

Rationale: The correct answer is D: 'Dizziness' and 'Headache'. ACE inhibitors like lisinopril are known to cause these common side effects due to their blood pressure-lowering effects. Choice A, 'Constipation', is not a common adverse effect associated with ACE inhibitors. While constipation can be a side effect of some medications, it is not typically seen with ACE inhibitors. Therefore, options A and B are incorrect choices.

2. The nurse on the postsurgical unit received a client who was transferred from the post-anesthesia care unit (PACU) and is planning care for this client. The nurse understands that staff should begin planning for this client’s discharge at which point during the hospitalization?

• A. Is admitted to the surgical unit
• B. Is transferred from the PACU to the postsurgical unit
• C. Is able to perform activities of daily living independently
• D. Has been assessed by the healthcare provider for the first time after surgery

Correct answer: A

Rationale: Discharge planning should begin as soon as the patient is admitted to the surgical unit to ensure a smooth transition. It is important to start early to address any potential barriers to discharge, coordinate resources, and provide adequate education and support. Choices B, C, and D are not the appropriate points to start discharge planning as they do not mark the beginning of the hospitalization phase related to the surgical unit.

3. The nurse enters a client’s room and the client is demanding release from the hospital. The nurse reviews the client’s record and noted that the client was admitted 2 days ago for treatment of an anxiety disorder, and the admission was voluntary. Which intervention should the nurse initiate first?

• A. Telephone the client’s family and have them persuade the client to stay
• B. Have the client read and sign all the appropriate self-discharge papers
• C. Explain to the client that he cannot leave because he asked for treatment
• D. Notify the client’s healthcare provider of the client’s stated intent to leave the hospital

Correct answer: D

Rationale: The correct intervention for the nurse to initiate first is to notify the client’s healthcare provider of the client’s stated intent to leave the hospital. This action is crucial as it ensures that the client’s care and safety are appropriately managed. Option A is not the best choice as involving the family to persuade the client may not address the client's underlying concerns. Option B is incorrect because having the client sign self-discharge papers without further assessment is not appropriate. Option C is also incorrect as the client's request for treatment does not prevent them from leaving if they are deemed competent to make that decision.

4. In patients with heart failure, which type of diet is most recommended?

• A. High-sodium
• B. Low-sodium
• C. High-fat
• D. Low-carbohydrate

Correct answer: B

Rationale: In patients with heart failure, a low-sodium diet is most recommended. This type of diet helps manage fluid retention by reducing the amount of sodium in the body. Excess sodium can lead to fluid accumulation, putting additional strain on the heart. High-sodium diets can exacerbate symptoms of heart failure by causing fluid retention and increasing blood pressure. High-fat and low-carbohydrate diets are not specifically recommended for heart failure patients and may not address the underlying issues related to fluid balance and heart function.

5. In a routine sputum analysis, which of the following indicates proper nursing action before sputum collection?

• A. Secure a clean container
• B. Discard the container if the outside becomes soiled
• C. Rinse the client's mouth with water after collection
• D. Tell the client that 4 tablespoons of sputum are needed

Correct answer: A

Rationale: Corrected Rationale: Before sputum collection, it is crucial to use a clean container to prevent specimen contamination. This step is essential to ensure accurate test results and to avoid introducing external particles or bacteria into the sample. Choice B is incorrect because discarding the container if the outside becomes soiled is not a standard practice before collection. Choice C is incorrect as rinsing the client's mouth with Listerine after collection can introduce unnecessary substances into the specimen. Choice D is incorrect as the amount of sputum needed should be determined by the healthcare provider, not the client.

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