Nursing Elites

1. A client with hypertension is prescribed a calcium channel blocker. Which client statement indicates that further teaching is needed?

• A. ‘I will take my medication at the same time every day.’
• B. ‘I should avoid drinking grapefruit juice while on this medication.’
• C. ‘I should increase my intake of calcium-rich foods.’
• D. ‘I should reduce my fluid intake to control my blood pressure.’

Correct answer: D

Rationale: The correct answer is D. The statement ‘I should reduce my fluid intake to control my blood pressure’ indicates a misunderstanding. It is important to note that fluid restriction is not typically necessary when taking calcium channel blockers. Choices A, B, and C demonstrate good understanding of medication adherence, dietary precautions, and nutrition recommendations when taking a calcium channel blocker, making them incorrect choices for further teaching.

2. At 0600 while admitting a woman for a scheduled repeat cesarean section (C-Section), the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first?

• A. Ensure preoperative lab results are available
• B. Start prescribed IV with lactated Ringer's
• C. Inform the anesthesia care provider
• D. Contact the client's obstetrician

Correct answer: C

Rationale: The correct action for the nurse to take first is to inform the anesthesia care provider. The patient's ingestion of coffee violates the NPO (nothing by mouth) guidelines before surgery, which increases the risk of aspiration during anesthesia. Informing the anesthesia care provider promptly allows for appropriate assessment and decision-making regarding the patient's anesthesia plan. Ensuring preoperative lab results, starting an IV, or contacting the obstetrician can be important steps but addressing the NPO violation and its implications on anesthesia safety take precedence.

3. The nurse is assessing a client with left-sided heart failure. Which assessment finding requires immediate intervention?

• A. Jugular venous distention
• B. Shortness of breath
• C. Crackles in the lungs
• D. Peripheral edema

Correct answer: C

Rationale: In a client with left-sided heart failure, crackles in the lungs are a critical assessment finding that necessitates immediate intervention. Crackles indicate pulmonary congestion, a sign of worsening heart failure that requires prompt attention to prevent respiratory distress. Jugular venous distention, shortness of breath, and peripheral edema are also common in heart failure, but crackles specifically point to pulmonary involvement and the urgent need for intervention.

4. The nurse is caring for a client who is 2 days postoperative following abdominal surgery. The client reports pain at the incision site and a small amount of purulent drainage is noted. What is the most appropriate nursing action?

• A. Apply a sterile dressing to the incision.
• B. Reinforce the dressing and document the findings.
• C. Remove the dressing and assess the incision site.
• D. Notify the healthcare provider.

Correct answer: D

Rationale: The correct answer is to notify the healthcare provider. Purulent drainage at the incision site is concerning as it may indicate an infection. The healthcare provider needs to be informed promptly to initiate appropriate treatment. Applying a sterile dressing (Choice A) may not address the underlying issue of infection. Reinforcing the dressing and documenting findings (Choice B) is important but should be preceded by notifying the healthcare provider. Removing the dressing and assessing the incision site (Choice C) may disturb the area and should be done under the guidance of the healthcare provider.

5. When a male Korean-American client looks away when asked by the nurse to describe his problem, what is the best initial nursing action?

• A. Ask for assistance from social services to find a Korean interpreter.
• B. Establish indirect eye contact with the client.
• C. Allow several minutes for the client to respond.
• D. Repeat the question using simpler language.

Correct answer: C

Rationale: In this scenario, the best initial nursing action is to allow several minutes for the client to respond. This approach respects the cultural norms of the client, as in some cultures, direct eye contact may be perceived as disrespectful or intrusive. By giving the client time to gather his thoughts and respond at his own pace, the nurse promotes effective communication and demonstrates cultural sensitivity. Asking for assistance from social services to find a Korean interpreter (Choice A) may be necessary for further communication but is not the best initial action. Establishing indirect eye contact (Choice B) may still make the client uncomfortable. Repeating the question using simpler language (Choice D) may not address the underlying cultural aspect affecting the client's response.

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