Nursing Elites

1. A client is admitted with a diagnosis of fluid volume deficit. Which clinical finding would the nurse expect?

• A. Bounding pulse
• B. Bradycardia
• C. Oliguria
• D. Dry mucous membranes

Correct answer: D

Rationale: Dry mucous membranes (D) are a common clinical finding indicating fluid volume deficit. In dehydration, there is insufficient fluid in the body, leading to dry mucous membranes due to decreased saliva production. Bounding pulse (A) is associated with fluid volume excess, not deficit. Bradycardia (B) and oliguria (C) are not typical clinical findings of fluid volume deficit but may be seen in fluid volume excess or other conditions.

2. The client, who is newly diagnosed with arteriosclerosis and is obese, is being educated by the nurse on reducing the risk of a heart attack or stroke. Which health promotion brochure should the nurse provide to this client?

• A. Monitoring Your Blood Pressure at Home
• B. Smoking Cessation as a Lifelong Commitment
• C. Decreasing Cholesterol Levels Through Diet
• D. Stress Management for a Healthier You

Correct answer: C

Rationale: The most significant risk factor contributing to arteriosclerosis is excess dietary fat, particularly saturated fat and cholesterol. Therefore, the most crucial brochure for the nurse to provide to the client focuses on decreasing cholesterol levels through diet to help reduce the risk of heart attack or stroke.

3. When taking a client's blood pressure, the healthcare professional is unable to distinguish the point at which the first sound was heard. What is the best action for the healthcare professional to take?

• A. Deflate the cuff completely and immediately reattempt the reading.
• B. Reinflate the cuff completely and leave it inflated for 90 to 110 seconds before taking the second reading.
• C. Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading.
• D. Document the exact level visualized on the sphygmomanometer where the first fluctuation was seen.

Correct answer: C

Rationale: The correct action when unable to distinguish the point of the first sound during blood pressure measurement is to deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading. This allows blood flow to return to the extremity, ensuring a more accurate reading the second time. It is important to ensure that the cuff is fully deflated and the appropriate wait time is given to obtain an accurate blood pressure measurement.

4. What action should the nurse implement to prepare a client for the potential side effects of a newly prescribed medication?

• A. Assess the client for health alterations that may be impacted by the effects of the medication
• B. Teach the client how to administer the medication to promote the best absorption
• C. Administer a half dose and observe the client for side effects before administering a full dosage
• D. Encourage the client to drink plenty of fluids to promote effective drug distribution

Correct answer: A

Rationale: Before initiating a new medication, the nurse should conduct a thorough assessment of the client to identify any pre-existing health conditions or risk factors that could be affected by the medication. This assessment helps in establishing a baseline for monitoring potential side effects and determining the medication's appropriateness for the client. Choice B is incorrect as teaching the client how to administer the medication does not directly address preparing for potential side effects. Choice C is incorrect because administering a half dose without a proper assessment could be unsafe. Choice D is incorrect as encouraging fluid intake is not directly related to preparing for potential side effects of a medication.

5. The nurse is providing discharge teaching to a client with a new prescription for warfarin (Coumadin). Which dietary instruction should the nurse include?

• A. Avoid foods high in vitamin K
• B. Increase intake of leafy green vegetables
• C. Consume a consistent amount of foods high in potassium
• D. Limit intake of high-protein foods

Correct answer: A

Rationale: The correct dietary instruction for a client taking warfarin is to avoid foods high in vitamin K. Warfarin is an anticoagulant that works by inhibiting vitamin K-dependent clotting factors. Consuming foods high in vitamin K, such as leafy green vegetables, can antagonize the effects of warfarin, potentially leading to treatment inefficacy or fluctuations in anticoagulation levels. Therefore, clients on warfarin therapy should be advised to avoid foods high in vitamin K to maintain the effectiveness of the medication. Choices B, C, and D are incorrect because increasing leafy green vegetables (choice B) would introduce more vitamin K, consuming a consistent amount of foods high in potassium (choice C) is not directly related to warfarin therapy, and limiting high-protein foods (choice D) is not a specific concern for clients on warfarin therapy.

Similar Questions