Nursing Elites

1. A client with Crohn's disease reports diarrhea. What intervention should the nurse implement?

• A. Instruct the client to drink clear fluids and avoid solid foods.
• B. Administer antidiarrheal medication as prescribed.
• C. Encourage a high-fiber diet and regular physical activity.
• D. Restrict fluid intake and monitor electrolytes.

Correct answer: C

Rationale: The correct intervention for a client with Crohn's disease reporting diarrhea is to encourage a high-fiber diet and regular physical activity. A high-fiber diet helps manage diarrhea in Crohn's disease by adding bulk to the stool and promoting more regular bowel movements. Instructing the client to drink clear fluids and avoid solid foods (Choice A) may not be appropriate as it can further exacerbate diarrhea. Administering antidiarrheal medication (Choice B) without addressing the underlying cause may not be the best initial approach. Encouraging a high-fiber diet and physical activity (Choice C) is beneficial for managing symptoms. Restricting fluid intake and monitoring electrolytes (Choice D) is not recommended as it can lead to dehydration, which is a concern in clients with diarrhea.

2. A client with a history of coronary artery disease is experiencing chest pain. What is the nurse's first action?

• A. Administer sublingual nitroglycerin
• B. Obtain a 12-lead electrocardiogram
• C. Call the healthcare provider
• D. Check the client's oxygen saturation

Correct answer: A

Rationale: The correct answer is A: Administer sublingual nitroglycerin. Sublingual nitroglycerin is the first-line treatment for chest pain related to coronary artery disease. It helps dilate the coronary arteries and improve blood flow to the heart, providing immediate relief from ischemia. Administering nitroglycerin promptly can help alleviate the chest pain and prevent further complications. Obtaining a 12-lead electrocardiogram (Choice B) is important but should not delay the administration of nitroglycerin. Calling the healthcare provider (Choice C) can be done after initiating immediate treatment. Checking the client's oxygen saturation (Choice D) is relevant but not the first action to take in this scenario.

3. The nurse is providing discharge teaching to a client with asthma. Which statement indicates the client understands how to use a rescue inhaler?

• A. I will use my rescue inhaler every morning to prevent asthma attacks.
• B. I should use my rescue inhaler when I start to experience wheezing.
• C. I will use my rescue inhaler when my peak flow meter reading is in the green zone.
• D. I will only use my rescue inhaler before going to bed.

Correct answer: B

Rationale: The correct answer is B: 'I should use my rescue inhaler when I start to experience wheezing.' A rescue inhaler is used during the onset of asthma symptoms, such as wheezing, to quickly open the airways. It is not intended for routine daily use or prevention, which is the role of a maintenance inhaler. Option A is incorrect because a rescue inhaler is not used for prevention but for immediate relief during an asthma attack. Option C is incorrect because the peak flow meter reading is used to monitor asthma control, not to determine when to use a rescue inhaler. Option D is incorrect because using a rescue inhaler only before going to bed does not address the need for immediate relief when wheezing or experiencing asthma symptoms.

4. A client with Addison's disease becomes confused and weak. What is the nurse's first action?

• A. Administer a dose of hydrocortisone immediately.
• B. Check the client’s electrolyte levels.
• C. Administer a dose of normal saline.
• D. Measure the client’s blood pressure in both arms.

Correct answer: A

Rationale: The correct answer is to administer a dose of hydrocortisone immediately. In Addison's disease, confusion and weakness can be signs of an adrenal crisis. Administering hydrocortisone promptly is crucial to prevent further deterioration. Checking electrolyte levels (Choice B) is important but not the first action in managing an acute adrenal crisis. Administering normal saline (Choice C) is not the priority in this situation. Measuring blood pressure in both arms (Choice D) is not the initial action needed to address the client's confusion and weakness in Addison's disease.

5. A client is receiving continuous intravenous heparin for a deep vein thrombosis. Which laboratory result should the nurse monitor to ensure therapeutic heparin levels?

• A. International normalized ratio (INR)
• B. Activated partial thromboplastin time (aPTT)
• C. Hemoglobin
• D. Platelet count

Correct answer: B

Rationale: The activated partial thromboplastin time (aPTT) is the most accurate measure of heparin's therapeutic effect. Heparin increases the time it takes for blood to clot, and the aPTT helps determine whether the dose is within the desired range for anticoagulation therapy. Monitoring the INR, hemoglobin, or platelet count is not specific to assessing therapeutic heparin levels and may not reflect the anticoagulant effect of heparin.

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