Nursing Elites

1. A home health nurse is making preparations for morning visits. Which one of the following clients should the nurse visit first?

• A. A client with brain attack (stroke) receiving tube feedings
• B. A client with congestive heart failure complaining of nighttime dyspnea
• C. A client who had a thoracotomy 6 months ago
• D. A client with Parkinson’s disease

Correct answer: B

Rationale: The correct answer is B. The client with congestive heart failure complaining of nighttime dyspnea should be seen first as airway management is a priority in nursing care. This client's symptoms indicate potential respiratory distress, requiring immediate attention. Choices A, C, and D involve clients who are more stable and do not present with urgent or acute conditions that require immediate intervention. Choice A with a client receiving tube feedings for a stroke may require attention, but the urgency of addressing potential respiratory distress in choice B takes precedence. Choice C, a client who had a thoracotomy 6 months ago, unless presenting with acute distress, does not necessitate immediate attention. Choice D, a client with Parkinson's disease, is usually a chronic condition that does not typically require immediate intervention for the described scenario.

2. The physician prescribes captopril (Capoten) 25mg po tid for the client with hypertension. Which of the following adverse reactions can occur with administration of Capoten?

• A. Tinnitus
• B. Persistent cough
• C. Muscle weakness
• D. Diarrhea

Correct answer: B

Rationale: A persistent cough might be related to an adverse reaction to captopril (Capoten). Tinnitus (choice A) and diarrhea (choice D) are not commonly associated adverse reactions of captopril. Muscle weakness (choice C) might occur initially but is not considered a common adverse effect of captopril. Therefore, the correct answer is B, persistent cough, as it is a known adverse reaction to captopril.

3. The nurse is preparing a client for mammography. To prepare the client for a mammogram, the nurse should tell the client:

• A. To omit creams, powders, or deodorants before the exam
• B. To restrict fat intake for 1 week before the test
• C. That mammography replaces the need for self-breast exams
• D. That mammography requires a higher dose of radiation than an x-ray

Correct answer: A

Rationale: The client undergoing a mammogram should be instructed to omit deodorants or powders beforehand because they can interfere with the imaging results. Answer A is correct as it aligns with the preparation needed before a mammogram to ensure accurate results. Answer B is incorrect because there is no requirement for fat intake restrictions before a mammogram. Answer C is incorrect because mammography does not replace the necessity of self-breast exams; both are crucial for maintaining breast health. Answer D is incorrect because a mammogram does not require higher doses of radiation than an x-ray. In fact, mammography uses a low dose of radiation to create images for breast examination.

4. When assessing a client for risk of hyperphosphatemia, which piece of information is most important for the nurse to obtain?

• A. A history of radiation treatment in the neck region
• B. A history of recent orthopedic surgery
• C. A history of minimal physical activity
• D. A history of the client's food intake

Correct answer: A

Rationale: The correct answer is a history of radiation treatment in the neck region. Previous radiation to the neck may have damaged the parathyroid glands, which are crucial for calcium and phosphorus regulation. This damage can lead to disruptions in phosphorus levels, increasing the risk of hyperphosphatemia. Choices B, C, and D are not as directly related to phosphorus regulation. Orthopedic surgery, minimal physical activity, and food intake are more closely associated with calcium levels rather than phosphorus regulation. Therefore, it is essential for the nurse to focus on obtaining information about a history of radiation treatment in the neck region when assessing the risk of hyperphosphatemia in a client.

5. To ensure safety while administering a nitroglycerine patch, what should the nurse do?

• A. Wear gloves
• B. Shave the area where the patch will be applied
• C. Wash the area thoroughly with soap and rinse with hot water
• D. Apply the patch to the buttocks

Correct answer: A

Rationale: To protect herself, the nurse should wear gloves when applying a nitroglycerine patch or cream. Answer B is incorrect because shaving the area where the patch will be applied might abrade the skin, increasing the risk of irritation. Answer C is incorrect because washing with hot water can vasodilate the skin, potentially increasing the absorption of nitroglycerine. Nitroglycerine patches should be applied to areas above the waist, making answer D incorrect as applying it to the buttocks is not recommended.

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