Nursing Elites

1. A client with a history of hypertension is prescribed enalapril (Vasotec). Which statement by the client indicates a need for further teaching?

• A. I will monitor my blood pressure regularly.
• B. I will report any signs of infection to my healthcare provider.
• C. I will avoid using salt substitutes.
• D. I will increase my intake of potassium-rich foods.

Correct answer: D

Rationale: The correct answer is D. Increasing potassium intake can lead to hyperkalemia, especially in clients taking ACE inhibitors like enalapril. Hyperkalemia is a potential side effect of ACE inhibitors and can be exacerbated by consuming potassium-rich foods. Monitoring blood pressure regularly (A) is important when taking antihypertensive medications. Reporting signs of infection (B) is crucial as ACE inhibitors can lower the immune response. Avoiding salt substitutes (C) is necessary because they may contain potassium chloride, leading to increased potassium levels, which can be harmful in combination with ACE inhibitors.

2. A female client is admitted with a tentative diagnosis of Guillain-Barre syndrome. Which finding is most important for the nurse to report to the healthcare provider?

• A. Facial weakness and difficulty speaking.
• B. Decreased deep tendon reflexes in the legs.
• C. Inability to move the eyes.
• D. Respiratory distress and cyanosis.

Correct answer: B

Rationale: In Guillain-Barre syndrome, decreased deep tendon reflexes are a critical finding that may indicate impending respiratory failure. This is due to the involvement of the peripheral nervous system affecting the muscles, including those involved in breathing. Reporting decreased deep tendon reflexes promptly is essential to prevent respiratory compromise. Facial weakness, difficulty speaking, and inability to move the eyes are common manifestations of Guillain-Barre syndrome but are not as immediately concerning as respiratory distress and impending respiratory failure.

3. The client is receiving warfarin (Coumadin) therapy. Which statement by the client indicates a need for further teaching?

• A. I will avoid eating foods high in vitamin K.
• B. I will use a soft toothbrush and an electric razor.
• C. I will keep all appointments for blood tests.
• D. I will avoid participating in contact sports.

Correct answer: D

Rationale: The correct answer is D because participating in contact sports can increase the risk of injury and bleeding in a client receiving warfarin therapy. Warfarin is a blood thinner, and activities with a higher risk of injury should be avoided to prevent bleeding complications. Choices A, B, and C are all correct statements for a client on warfarin therapy. Avoiding foods high in vitamin K helps maintain consistent anticoagulation levels, using a soft toothbrush and an electric razor reduces the risk of bleeding gums and cuts, and keeping appointments for blood tests ensures proper monitoring of the client's international normalized ratio (INR) levels.

4. A male client who had abdominal surgery has a nasogastric tube for suction, oxygen via nasal cannula, and complains of dry mouth. Which action should the nurse implement?

• A. Apply a petroleum-based lubricant to the lips.
• B. Give sips of water.
• C. Provide ice chips.
• D. Apply a water-soluble lubricant to the lips, oral mucosa, and nares.

Correct answer: D

Rationale: In this scenario, the correct action is to apply a water-soluble lubricant to the lips, oral mucosa, and nares. This helps in keeping the mucous membranes moist, which is essential for a client with a dry mouth due to the nasogastric tube and oxygen therapy. Choice A, applying a petroleum-based lubricant to the lips, is not suitable as it may not be safe for internal use. Choice B, giving sips of water, is contraindicated as the client has a nasogastric tube in place for suction. Choice C, providing ice chips, is also not recommended as the client needs proper lubrication to address dryness, not cold stimulation.

5. When caring for a client with a chest tube, which intervention is most important to include in the plan of care?

• A. Maintain continuous suction on the chest tube.
• B. Clamp the chest tube during client movement.
• C. Ensure that the chest tube is clamped for at least 8 hours each day.
• D. Keep the collection chamber below the level of the chest.

Correct answer: D

Rationale: Keeping the collection chamber below the level of the chest is crucial in caring for a client with a chest tube. This positioning helps ensure proper drainage of fluids and prevents complications such as backflow of drainage into the chest cavity. Option A is incorrect as continuous suction can lead to excessive drainage and tissue damage. Option B is incorrect as clamping the chest tube during client movement can cause a buildup of pressure and compromise proper drainage. Option C is incorrect because clamping the chest tube for extended periods can impede the drainage process, leading to potential complications.

Similar Questions