Nursing Elites

1. A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates that the client may need suctioning?

• A. drowsiness
• B. complaint of nausea
• C. pulse rate of 92
• D. restlessness

Correct answer: D

Rationale: Restlessness is often a sign of respiratory distress or secretion build-up, indicating the need for suctioning. While drowsiness (choice A) can be a sign of hypoxia, it is not as immediate an indication for suctioning as restlessness. Complaint of nausea (choice B) and a pulse rate of 92 (choice C) are not directly related to the need for suctioning in a client on a volume-cycled ventilator.

2. When a client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer, which of the following should take priority in planning care?

• A. Esophagitis
• B. Leukopenia
• C. Fatigue
• D. Skin irritation

Correct answer: B

Rationale: Leukopenia should take priority in planning care for a client receiving external beam radiation to the mediastinum for bronchial cancer because it is a serious side effect that increases the risk of infection. Monitoring leukopenia is crucial to prevent complications. Esophagitis, fatigue, and skin irritation are also potential side effects of radiation therapy, but leukopenia poses a higher risk of life-threatening infections, requiring immediate attention.

3. The nurse is teaching an 87-year-old client methods for maintaining regular bowel movements. The nurse would caution the client to AVOID

• A. Glycerin suppositories
• B. Fiber supplements
• C. Laxatives
• D. Stool softeners

Correct answer: C

Rationale: The correct answer is C: Laxatives. Laxatives can be harsh on elderly clients, leading to dependence and potential side effects. While fiber supplements (B) and stool softeners (D) are generally safe options to promote regular bowel movements, laxatives should be used cautiously in older adults due to their potential risks. Glycerin suppositories (A) can also be a safe and effective option for managing constipation in the elderly, but laxatives should be avoided unless deemed necessary by a healthcare provider.

4. The client is receiving discharge teaching for heart failure. Which statement made by the client indicates a need for further teaching?

• A. I will weigh myself daily and report any significant weight gain to my healthcare provider.
• B. I will limit my sodium intake to help manage my heart failure.
• C. I will take my medications as prescribed by my healthcare provider.
• D. I will stop taking my medications if I feel better.

Correct answer: D

Rationale: Choice D is the correct answer because stopping medications when feeling better can be harmful in heart failure. It is essential to complete the full course of medication as prescribed by the healthcare provider to effectively manage heart failure. Choices A, B, and C demonstrate good understanding and compliance with heart failure management strategies, such as monitoring weight, restricting sodium intake, and adhering to prescribed medications, respectively.

5. A nurse is reinforcing discharge teaching with a client who has acute pancreatitis and a prescription for fat-soluble vitamin supplements. Which of the following supplements should the nurse include in the teaching?

• A. Vitamin A
• B. Vitamin B1
• C. Vitamin C
• D. Vitamin B12

Correct answer: A

Rationale: The correct answer is Vitamin A. Fat-soluble vitamins essential for patients with pancreatitis include A, D, E, and K, aiding in proper nutrient absorption. Vitamin B1 (Choice B), also known as thiamine, is a water-soluble vitamin and not a fat-soluble one. Vitamin C (Choice C) is another water-soluble vitamin and not a fat-soluble one. Vitamin B12 (Choice D) is also a water-soluble vitamin and not one of the fat-soluble vitamins crucial for patients with pancreatitis.

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