Nursing Elites

1. A client with heart failure is prescribed spironolactone. What is the nurse's priority intervention?

• A. Monitor the client's potassium levels closely.
• B. Assess for signs of hyperkalemia.
• C. Instruct the client to increase intake of potassium-rich foods.
• D. Increase the client’s fluid intake to prevent dehydration.

Correct answer: B

Rationale: The correct answer is B: Assess for signs of hyperkalemia. Spironolactone is a potassium-sparing diuretic, which can cause hyperkalemia (high potassium levels). Therefore, the nurse's priority intervention should be to assess the client for signs of hyperkalemia, such as muscle weakness, fatigue, and potentially dangerous cardiac arrhythmias. Monitoring potassium levels closely (choice A) is important but assessing for signs of hyperkalemia takes precedence. Instructing the client to increase intake of potassium-rich foods (choice C) can exacerbate hyperkalemia in this case. Increasing the client’s fluid intake to prevent dehydration (choice D) is not directly related to the potential side effect of spironolactone.

2. A client asks the nurse for information about reducing risk factors for BPH. Which information should the nurse provide?

• A. Increase physical activity
• B. Decrease alcohol consumption
• C. Reduce intake of dairy products
• D. Avoid caffeine and spicy foods

Correct answer: A

Rationale: The correct answer is A: Increase physical activity. Physical activity can help reduce the risk of benign prostatic hyperplasia (BPH) by improving overall circulation and reducing inflammation. While decreasing alcohol consumption and avoiding caffeine and spicy foods may help with symptom management, increasing physical activity is more strongly linked to the prevention of BPH.

3. A male client with HIV on antiretroviral therapy complains of constant hunger and thirst while losing weight. What action should the nurse implement?

• A. Check the client's glucose level with a glucometer.
• B. Measure the client's weight accurately.
• C. Reassure the client that weight will stabilize as viral load decreases.
• D. Increase the dose of saquinavir.

Correct answer: A

Rationale: The correct action for the nurse to implement is to check the client's glucose level with a glucometer. Constant hunger and thirst along with weight loss can be indicative of hyperglycemia, a possible side effect of saquinavir. Monitoring the client's glucose levels is crucial in this situation. Measuring the client's weight accurately (Choice B) is important for monitoring purposes but does not address the immediate concern of hunger, thirst, and weight loss. Reassuring the client that weight will stabilize as viral load decreases (Choice C) is not appropriate in this scenario as the symptoms described need immediate attention. Increasing the dose of saquinavir (Choice D) without assessing the client's glucose level can worsen the hyperglycemia.

4. During a neurologic assessment of a client with a suspected stroke, which finding is most concerning?

• A. Unilateral facial droop
• B. Slurred speech
• C. Weakness in one arm
• D. Sudden loss of consciousness

Correct answer: D

Rationale: Sudden loss of consciousness in a client with a suspected stroke is the most concerning finding as it indicates a more severe neurological event, such as brain stem involvement or hemorrhage, requiring immediate intervention. While unilateral facial droop, slurred speech, and weakness in one arm are all common signs of a stroke, sudden loss of consciousness signifies a critical condition that needs urgent attention and evaluation to prevent further complications.

5. The nurse is planning care for a client with a venous leg ulcer. Which intervention should the nurse include in the plan of care to promote healing?

• A. Apply compression therapy to the affected leg
• B. Keep the affected leg in a dependent position
• C. Massage the area surrounding the ulcer
• D. Encourage the client to elevate the leg for 2 hours daily

Correct answer: A

Rationale: Compression therapy is essential for managing venous leg ulcers as it helps improve venous return, reduces edema, and promotes healing. By applying compression therapy to the affected leg, the nurse can assist in enhancing circulation, reducing swelling, and aiding in the healing process. Keeping the affected leg in a dependent position can worsen venous insufficiency. Massaging the area surrounding the ulcer is contraindicated as it can cause further damage and delay healing. While encouraging the client to elevate the leg is beneficial, it is not as effective as compression therapy for promoting healing in venous leg ulcers.

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