Nursing Elites

1. A client asks the nurse for information about reducing risk factors for BPH. Which information should the nurse provide?

• A. Increase physical activity
• B. Decrease alcohol consumption
• C. Reduce intake of dairy products
• D. Avoid caffeine and spicy foods

Correct answer: A

Rationale: The correct answer is A: Increase physical activity. Physical activity can help reduce the risk of benign prostatic hyperplasia (BPH) by improving overall circulation and reducing inflammation. While decreasing alcohol consumption and avoiding caffeine and spicy foods may help with symptom management, increasing physical activity is more strongly linked to the prevention of BPH.

2. The healthcare provider is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for immediate action by the healthcare provider?

• A. Breath sounds are audible bilaterally
• B. Mist is visible in the T-piece
• C. Pulse oximetry of 88
• D. Client is unable to verbalize

Correct answer: C

Rationale: A pulse oximetry reading of 88 indicates hypoxia, which is a serious condition requiring immediate intervention. Adequate oxygenation is crucial for the client's well-being. Choices A and B are normal findings after endotracheal intubation. Hearing bilateral breath sounds and seeing mist in the T-piece indicate proper functioning of the endotracheal tube. While choice D may indicate an issue with speaking due to the endotracheal tube, it is not as critical as the hypoxia indicated by the low pulse oximetry reading.

3. A client with heart failure receiving furosemide develops muscle weakness. What is the nurse's priority action?

• A. Administer potassium supplements as prescribed.
• B. Monitor the client’s potassium levels.
• C. Instruct the client to increase their salt intake.
• D. Discontinue the furosemide.

Correct answer: B

Rationale: Muscle weakness in a client receiving furosemide (a diuretic) is often a sign of hypokalemia, as furosemide increases potassium loss. Monitoring potassium levels is essential to identify and address any imbalances and prevent complications such as arrhythmias. Administering potassium supplements without monitoring the levels can lead to hyperkalemia, which has its own set of serious complications. Instructing the client to increase salt intake is not appropriate in this situation as it does not address the underlying electrolyte imbalance. Discontinuing furosemide abruptly can worsen heart failure symptoms; therefore, monitoring potassium levels and adjusting the treatment accordingly is the most appropriate action.

4. A client with atrial fibrillation is prescribed warfarin. Which instruction should the nurse include in the teaching?

• A. Maintain a consistent intake of leafy green vegetables
• B. Use an electric razor when shaving
• C. Monitor blood pressure daily
• D. Avoid eating bananas and oranges

Correct answer: B

Rationale: Clients on warfarin are at increased risk of bleeding due to its anticoagulant effects. Using an electric razor reduces the risk of cuts and bleeding, which is an important safety precaution. While leafy greens should not be avoided, their intake should be consistent to maintain a stable level of vitamin K in the body. Monitoring blood pressure daily is important for other conditions but not directly related to warfarin therapy. Avoiding bananas and oranges is not a standard instruction for clients on warfarin.

5. The nurse receives a report on an older adult client with middle stage dementia. What information suggests the nurse should do immediate follow-up rather than delegate care to the nursing assistant?

• A. Has had a change in respiratory rate with an increase of 2 breaths
• B. Has had a change in heart rate with an increase of 10 beats
• C. Was minimally responsive to voice and touch
• D. Has had a blood pressure change with a drop of 8 mmHg systolic

Correct answer: C

Rationale: A change in responsiveness, as indicated by being minimally responsive to voice and touch, suggests a potential acute issue that requires immediate nursing assessment and intervention rather than delegation. Changes in vital signs (choices A, B, D) can be important but do not always indicate an immediate need for nursing intervention compared to a change in responsiveness.

Similar Questions