Nursing Elites

1. A client with a history of atrial fibrillation is prescribed dabigatran (Pradaxa). Which instruction should the nurse include in the client's teaching?

• A. Take the medication with food to improve absorption.
• B. Avoid foods high in vitamin K.
• C. Take the medication at the same time each day.
• D. Increase your intake of high-potassium foods.

Correct answer: C

Rationale: The correct instruction for the nurse to include in the client's teaching regarding dabigatran (Pradaxa) is to take the medication at the same time each day. This ensures a consistent blood level and effectiveness of the medication, which is crucial in managing atrial fibrillation and preventing complications. It helps maintain a steady therapeutic effect and reduces the risk of erratic drug levels in the body.

2. A client is scheduled for a colonoscopy. Which instruction should the nurse provide?

• A. Eat a light breakfast on the day of the procedure.
• B. You will need to drink a bowel preparation solution before the procedure.
• C. Avoid all liquids for 24 hours before the procedure.
• D. You can continue taking your blood thinners until the day of the procedure.

Correct answer: B

Rationale: The correct instruction for a client scheduled for a colonoscopy is to drink a bowel preparation solution before the procedure. This solution helps cleanse the colon, ensuring clear visualization during the colonoscopy procedure. Choice A is incorrect because a light breakfast is usually recommended the day before the procedure, not on the day of the colonoscopy. Choice C is incorrect as it is important to stay hydrated and follow specific instructions regarding liquid intake. Choice D is incorrect as blood thinners may need to be adjusted or stopped before the colonoscopy to reduce the risk of bleeding during the procedure.

3. Why is a low-protein diet recommended for a client with hepatic encephalopathy?

• A. Hyperglycemia
• B. Hypoglycemia
• C. Increased ammonia levels
• D. Electrolyte imbalance

Correct answer: C

Rationale: A low-protein diet is recommended for clients with hepatic encephalopathy to reduce ammonia levels. Ammonia, a byproduct of protein metabolism, can accumulate in the blood due to impaired liver function. Elevated ammonia levels can lead to worsening hepatic encephalopathy, a condition characterized by cognitive and neurological disturbances. Therefore, by limiting protein intake, the production of ammonia is reduced, thereby helping to manage hepatic encephalopathy. Choices A, B, and D are incorrect because hepatic encephalopathy is not primarily related to hyperglycemia, hypoglycemia, or electrolyte imbalance. The focus is on reducing ammonia levels to improve the condition.

4. A client is receiving chemotherapy and is at risk for neutropenia. Which precaution should the nurse implement?

• A. Encourage regular visitors to boost morale.
• B. Ensure the client receives live vaccines.
• C. Place the client in a private room.
• D. Provide a diet high in fresh fruits and vegetables.

Correct answer: C

Rationale: Placing the client in a private room is crucial to protect them from infections due to their compromised immune system. Neutropenia, a common side effect of chemotherapy, decreases white blood cell count, making the client more susceptible to infections. By placing the client in a private room, exposure to pathogens from other individuals is minimized, reducing the risk of infection and helping maintain the client's health during this vulnerable period.

5. The healthcare provider formulates a nursing diagnosis of 'High risk for ineffective airway clearance' for a client with myasthenia gravis. What is the most likely cause for this nursing diagnosis?

• A. Pain during coughing.
• B. Diminished cough effort.
• C. Thick, dry secretions.
• D. Excessive inflammation.

Correct answer: B

Rationale: Clients with myasthenia gravis commonly experience muscle weakness, including in the muscles used for coughing. This diminished cough effort can lead to ineffective airway clearance, increasing the risk of respiratory complications. Therefore, the most likely cause for the nursing diagnosis 'High risk for ineffective airway clearance' in a client with myasthenia gravis is the diminished cough effort due to muscle weakness.

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