Nursing Elites

1. A client with hypertension has been prescribed a calcium channel blocker. What should the nurse include in the client's teaching plan?

• A. Monitor heart rate regularly
• B. Avoid potassium-rich foods
• C. Increase fluid intake to avoid dehydration
• D. Take the medication with food

Correct answer: A

Rationale: Corrected Rationale: Calcium channel blockers can cause bradycardia, so it is important for the client to monitor their heart rate regularly. This helps detect any significant changes in heart rate that may require medical attention. Choice B is incorrect because there is no need to avoid potassium-rich foods with calcium channel blockers. Choice C is incorrect as increasing fluid intake is not specifically related to calcium channel blockers. Choice D is incorrect as calcium channel blockers are usually taken with or without food, depending on the specific medication, but not specifically on an empty stomach.

2. An older client is admitted with fluid volume deficit and dehydration. Which assessment finding is the best indicator of hydration status?

• A. Urine specific gravity of 1.040.
• B. Systolic blood pressure decreases by 10 points when standing.
• C. The client denies feeling thirsty.
• D. Skin turgor exhibits tenting on the forearm.

Correct answer: A

Rationale: In the context of fluid volume deficit and dehydration, urine specific gravity of 1.040 is the best indicator of hydration status. High urine specific gravity indicates concentrated urine, suggesting dehydration. Choice B, systolic blood pressure decreasing when standing, is more indicative of orthostatic hypotension rather than hydration status. Choice C, denial of thirst, is a subjective finding and may not always reflect actual hydration status. Choice D, skin turgor exhibiting tenting on the forearm, is a sign of dehydration but may not be as accurate as urine specific gravity in assessing hydration status.

3. A 17-year-old adolescent reports flu-like symptoms and is brought to the emergency room. What intervention should the nurse implement first?

• A. Assess the client's temperature.
• B. Place a mask on the client.
• C. Obtain a chest X-ray per protocol.
• D. Determine the client's blood pressure.

Correct answer: B

Rationale: The correct answer is to place a mask on the client. This intervention is crucial in preventing the spread of infections like the flu, especially in a healthcare setting where the risk of transmission is high. Assessing the client's temperature (Choice A) can be important but is not the priority in this situation. Obtaining a chest X-ray (Choice C) and determining the client's blood pressure (Choice D) are not the immediate interventions needed for a 17-year-old reporting flu-like symptoms.

4. After repositioning an immobile client, the nurse observes an area of hyperemia. What action should the nurse take to assess for blanching?

• A. Document the presence in the client’s record.
• B. Apply light pressure over the area.
• C. Apply heat to the area and reassess in 30 minutes.
• D. Apply cold compresses to reduce the redness.

Correct answer: B

Rationale: The correct action for the nurse to take to assess for blanching in an area of hyperemia is to apply light pressure over the area. Blanching is the temporary whitening of the skin when pressure is applied and then released, indicating that the blood flow is returning to the area. Applying light pressure helps in determining if the hyperemic area blanches, ensuring that blood flow is adequate. Choices A, C, and D are incorrect because documenting findings, applying heat, or using cold compresses are not appropriate actions for assessing blanching in an area of hyperemia.

5. A client receiving chemotherapy has severe neutropenia. What snack is best for the nurse to recommend?

• A. Baked apples with raisins.
• B. Yogurt with fresh berries.
• C. Avocados and cheese.
• D. Fresh fruit salad.

Correct answer: B

Rationale: For a client with severe neutropenia, it is crucial to recommend a snack that is low in bacteria to reduce the risk of infection. Yogurt with fresh berries is an excellent choice as it is not only low in bacteria but also provides nutritional value. Baked apples with raisins (choice A) may not be ideal as the preparation process could introduce bacteria. Avocados and cheese (choice C) may not be the best option due to their potential bacterial content. Fresh fruit salad (choice D) may have a higher risk of bacterial contamination compared to yogurt with fresh berries.

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