Nursing Elites

1. A client tells the nurse about working out with a personal trainer and swimming three times a week in an effort to lose weight and sleep better. The client states that it still takes hours to fall asleep at night. Which action should the nurse implement?

• A. Advise the client to reduce exercise intensity
• B. Ask the client for a description of the exercise schedule that is being followed
• C. Encourage the client to try relaxation techniques before bed
• D. Suggest avoiding water-based exercise before bed

Correct answer: B

Rationale: Asking the client for a description of the exercise schedule being followed is the most appropriate action for the nurse to take in this scenario. Understanding the timing and intensity of the client's exercise routine can help identify if the activity is contributing to sleep disturbances. Exercise too close to bedtime can cause difficulty falling asleep. Choices A, C, and D do not directly address the need to assess the exercise schedule and may not provide the necessary information to identify the potential cause of the client's sleep issue.

2. During an initial assessment, a healthcare provider notes that a client has elevated blood pressure. Which of the following findings is considered a major risk factor for coronary artery disease?

• A. Elevated HDL cholesterol
• B. Low LDL cholesterol
• C. Elevated blood pressure
• D. Low triglyceride levels

Correct answer: C

Rationale: Elevated blood pressure is a significant risk factor for coronary artery disease because it increases the strain on the arteries, leading to potential damage and a higher risk of developing coronary artery disease. Elevated HDL cholesterol (Choice A) is actually considered beneficial as it helps reduce the risk of heart disease. Low LDL cholesterol (Choice B) is also beneficial as high levels of LDL are associated with an increased risk of coronary artery disease. Low triglyceride levels (Choice D) are not typically considered a major risk factor for coronary artery disease.

3. A client with chronic obstructive pulmonary disease (COPD) is being discharged home. What should the nurse include in the discharge teaching?

• A. Limit fluid intake to prevent lung congestion
• B. Avoid all physical activity to conserve energy
• C. Perform pursed-lip breathing during activities
• D. Increase oxygen flow rate if shortness of breath occurs

Correct answer: C

Rationale: The correct answer is C. Pursed-lip breathing helps control breathing and improves oxygen exchange in clients with COPD. It can ease shortness of breath during activities and should be included in discharge teaching to manage symptoms. Option A is incorrect as adequate fluid intake is important for thinning mucus in COPD. Option B is wrong as physical activity, as tolerated, is beneficial for COPD patients. Option D is also incorrect because changing oxygen flow rate without healthcare provider guidance can be dangerous.

4. 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.

5. The mother of a 2-day-old infant girl expresses concern about a 'flea bite' type rash on her daughter's body. The nurse identifies a pink papular rash with vesicles superimposed over the thorax, back, buttocks, and abdomen. Which explanation should the nurse offer?

• A. We need to monitor the rash for signs of worsening or fever
• B. Your baby may have an allergic reaction to laundry detergent
• C. This is a common newborn rash that will resolve after several days
• D. This is likely a bacterial infection requiring antibiotics

Correct answer: C

Rationale: The rash described is typical of erythema toxicum neonatorum, a common and benign newborn rash that resolves on its own within a few days. No treatment is necessary, and the nurse should reassure the mother. Choice A is incorrect as the rash is self-limiting and does not require monitoring for worsening signs or fever. Choice B is incorrect as erythema toxicum neonatorum is not caused by an allergic reaction to laundry detergent. Choice D is incorrect as this rash is not indicative of a bacterial infection that requires antibiotics.

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