Nursing Elites

1. A male client with diabetes mellitus is transferred from the hospital to a rehabilitation facility following treatment for a stroke resulting in right hemiplegia. He tells the nurse that his feet are always uncomfortably cool at night, preventing him from falling asleep. Which action should the nurse implement?

• A. Provide a warming pad for his feet
• B. Medicate the client with a prescribed sedative.
• C. Use a bed cradle to keep the covers off his feet.
• D. Place warm blankets next to the client's feet.

Correct answer: D

Rationale: Placing warm blankets next to the client's feet is the most appropriate action to provide warmth and comfort. This method is safe and effective in addressing the client's complaint of uncomfortably cool feet at night. Providing a warming pad (Choice A) may pose a risk of burns or injury, especially for a client with decreased sensation due to diabetes. Mediating the client with a sedative (Choice B) does not address the underlying issue of cool feet and may not be necessary. Using a bed cradle (Choice C) to hold the covers off the feet does not directly address the client's need for warmth and comfort.

2. The nurse is assessing a client who reports sudden onset of severe eye pain and blurred vision. What is the priority nursing intervention?

• A. Administer prescribed pain medication.
• B. Notify the healthcare provider immediately.
• C. Place an eye patch over the affected eye.
• D. Prepare the client for a CT scan.

Correct answer: B

Rationale: The correct answer is to notify the healthcare provider immediately (Choice B). Sudden severe eye pain and blurred vision can indicate acute angle-closure glaucoma, which is a medical emergency requiring prompt evaluation and treatment to prevent vision loss. Administering pain medication (Choice A) may provide temporary relief but does not address the underlying cause. Placing an eye patch (Choice C) may not be appropriate without knowing the exact cause of the symptoms. Preparing for a CT scan (Choice D) is not the immediate priority in this situation where urgent medical attention is needed.

3. A client with deep vein thrombosis (DVT) is being treated with warfarin. Which dietary instruction should the nurse provide?

• A. Avoid foods high in vitamin C
• B. Increase intake of green leafy vegetables
• C. Limit intake of foods high in vitamin K
• D. Avoid dairy products

Correct answer: C

Rationale: The correct answer is C: 'Limit intake of foods high in vitamin K'. Vitamin K can interfere with the effectiveness of warfarin, an anticoagulant medication commonly used to treat conditions like deep vein thrombosis (DVT). Patients on warfarin should maintain a consistent intake of vitamin K-rich foods and be monitored closely. Choices A, B, and D are incorrect because avoiding foods high in vitamin C, increasing intake of green leafy vegetables, and avoiding dairy products are not essential dietary instructions for a client on warfarin therapy for DVT.

4. What is the most critical initial intervention for a client who is actively seizing?

• A. Restrain the client to prevent injury
• B. Insert an oral airway
• C. Turn the client to the side
• D. Apply soft restraints to the wrists

Correct answer: C

Rationale: The most critical initial intervention for a client who is actively seizing is to turn the client to the side. This action helps maintain an open airway and prevents aspiration during a seizure. Restrain the client to prevent injury (Choice A) is incorrect because restraining a client during a seizure can lead to injury. Inserting an oral airway (Choice B) is not recommended as it can cause injury and is not necessary during an active seizure. Applying soft restraints to the wrists (Choice D) is also not recommended as it can lead to harm and does not address the immediate airway management needed during a seizure.

5. A client with fluid volume excess has gained 6.6 pounds. The nurse recognizes that this is equivalent to what volume of fluid?

• A. Two liters.
• B. Three liters.
• C. Four liters.
• D. Five liters.

Correct answer: B

Rationale: A weight gain of 6.6 pounds is approximately equivalent to 3 liters of fluid. It is important to remember that 1 liter of fluid is equal to 1 kg, which is approximately 2.2 pounds. Therefore, when the client gains 6.6 pounds, it translates to 3 liters of fluid. Choices A, C, and D are incorrect as they do not align with the conversion rate of 1 liter of fluid to 2.2 pounds.

Similar Questions