Nursing Elites

1. A client is receiving Cilostazol (Pletal) for peripheral arterial disease causing intermittent claudication. The nurse determines this medication is effective when the client reports which of the following?

• A. I am having fewer aches and pains.
• B. I do not have headaches anymore.
• C. I am able to walk further without leg pain.
• D. My toes are turning grayish black in color.

Correct answer: C

Rationale: The correct answer is C. Cilostazol improves blood flow to the muscles, which helps alleviate symptoms of intermittent claudication. An improvement in walking distance without leg pain indicates the effectiveness of the medication. Choices A and B are not directly related to the expected outcome of Cilostazol therapy for intermittent claudication. Choice D is concerning for a potential adverse effect and should be reported to the healthcare provider immediately.

2. A patient who is taking trimethoprim-sulfamethoxazole (TMP-SMX) calls to report developing an all-over rash. What action should the nurse instruct the patient to perform?

• A. Increase fluid intake.
• B. Take diphenhydramine.
• C. Stop taking TMP-SMX immediately.
• D. Continue taking the medication.

Correct answer: C

Rationale: When a patient develops an all-over rash while taking trimethoprim-sulfamethoxazole (TMP-SMX), it may indicate a serious drug reaction. In this case, the patient should stop taking the medication immediately and notify their healthcare provider. Increasing fluid intake (Choice A) may be beneficial in some cases but is not the priority when a serious drug reaction is suspected. Taking diphenhydramine (Choice B) may help with itching but does not address the underlying issue of a potential drug reaction. Continuing the medication (Choice D) is not advisable when a serious adverse reaction such as a widespread rash occurs.

3. Oxygen via nasal cannula has been prescribed for a client with emphysema. The nurse checks the physician’s orders to ensure that the prescribed flow is not greater than:

• A. 1 L/min
• B. 3 L/min
• C. 4 L/min
• D. 6 L/min

Correct answer: B

Rationale: The correct answer is B, 3 L/min. Clients with emphysema typically receive oxygen at a flow rate of 1 to 2 L/min, with a maximum of 3 L/min. Higher flow rates can lead to oxygen toxicity in these clients, so it's crucial to adhere to the prescribed limits. Choice A (1 L/min) is too low and may not provide adequate oxygenation for the client. Choices C (4 L/min) and D (6 L/min) exceed the recommended flow rates for clients with emphysema and can increase the risk of oxygen toxicity.

4. A client with chronic heart failure is being taught by a nurse about the importance of daily weights. Which of the following instructions should the nurse include?

• A. Weigh yourself at the same time every day.
• B. Use the same scale for weighing each time.
• C. Record your weight in a journal or log.
• D. Report any weight gain of more than 2 to 3 pounds in a day.

Correct answer: D

Rationale: The correct instruction for a client with chronic heart failure is to report any weight gain of more than 2 to 3 pounds in a day. This weight gain may indicate fluid retention, which is a critical sign of worsening heart failure. Weighing at the same time every day and using the same scale for consistency are good practices, but the crucial action is to promptly report significant weight gain, as stated in option D. Recording the weight in a journal or log can be helpful for tracking trends, but immediate reporting of weight gain is essential for timely intervention in heart failure management. Therefore, option D is the most appropriate instruction for this client.

5. Which client should the nurse recognize as most likely to experience sleep apnea?

• A. Middle-aged female who takes a diuretic nightly.
• B. Obese older male client with a short, thick neck.
• C. Adolescent female with a history of tonsillectomy.
• D. School-aged male with a history of hyperactivity disorder.

Correct answer: B

Rationale: The correct answer is B. Sleep apnea is characterized by pauses in breathing during sleep, often due to a collapsed or blocked airway. Obesity and having a short, thick neck are risk factors for sleep apnea because excess fat around the neck can obstruct the airway. Option A (middle-aged female who takes a diuretic nightly) does not present as a common risk factor for sleep apnea. Option C (adolescent female with a history of tonsillectomy) may have had tonsils removed, which could reduce the risk of sleep apnea. Option D (school-aged male with a history of hyperactivity disorder) is not directly associated with an increased risk of sleep apnea.

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