Nursing Elites

1. A client has a new prescription for captopril. Which of the following instructions should the nurse include?

• A. Take this medication with food.
• B. You may experience a persistent dry cough.
• C. Increase your intake of foods high in potassium.
• D. You should avoid eating grapefruit while taking this medication.

Correct answer: B

Rationale: The correct answer is B. A persistent dry cough is a common side effect of captopril, an ACE inhibitor, and should be included in the teaching. Choice A is incorrect because captopril is usually taken on an empty stomach. Choice C is incorrect because captopril can increase potassium levels, so there is no need to further increase potassium intake. Choice D is incorrect because captopril does not interact with grapefruit.

2. A nurse is preparing to measure the temperature of an infant. Which of the following actions should the nurse take?

• A. Place the tip of the thermometer under the center of the infant's axilla.
• B. Pull the pinna of the infant's ear forward before inserting the probe.
• C. Insert the probe 3.8 cm (1.5 inches) into the infant's rectum.
• D. Insert the thermometer in front of the infant's tongue.

Correct answer: A

Rationale: The correct method for measuring an infant's temperature is by placing the tip of the thermometer under the center of the infant's axilla (armpit). This method is non-invasive and safe. Pulling the pinna of the ear forward is used when taking a tympanic temperature. Inserting the probe into the rectum is done for rectal temperature measurement, which is not recommended as an initial method in infants. Inserting the thermometer in front of the infant's tongue is not a standard method for measuring temperature in infants.

3. A nurse is caring for a client who is postoperative following a total knee arthroplasty. Which of the following interventions should the nurse include in the plan of care?

• A. Apply heat to the incision site.
• B. Keep the client's knee flexed while in bed.
• C. Place a pillow under the client's knee while in bed.
• D. Place a pillow under the client's lower legs.

Correct answer: D

Rationale: Placing a pillow under the client's lower legs is the correct intervention because it helps prevent pressure on the incision site and promotes circulation. Elevating the lower legs also aids in reducing swelling and improving blood flow. Applying heat to the incision site (Choice A) is contraindicated in the early postoperative period as it can increase inflammation and the risk of infection. Keeping the client's knee flexed while in bed (Choice B) may lead to contractures or limited extension of the knee joint. Placing a pillow under the client's knee (Choice C) may cause hyperextension of the knee, which is also not recommended post knee arthroplasty.

4. A client is preparing advance directives. Which of the following statements by the client indicates an understanding of advance directives?

• A. I cannot change my instructions once I have signed them.
• B. My doctor will need to approve my advance directives.
• C. I need a witness to sign my advance directives.
• D. I have the right to refuse treatment.

Correct answer: D

Rationale: The correct answer is D: 'I have the right to refuse treatment.' This statement shows an understanding of advance directives because they allow individuals to specify their treatment preferences in advance, including the right to refuse treatment. Choices A, B, and C are incorrect. Choice A is inaccurate as individuals can update or change their advance directives at any time. Choice B is incorrect because while a doctor may discuss advance directives with the client, approval is not required for the directives to be valid. Choice C is also incorrect as a witness is typically required to verify the client's signature, not the other way around.

5. A client is receiving radiation therapy to the head and neck. Which of the following interventions should the nurse include?

• A. Instruct the client to use an alcohol-free mouthwash.
• B. Apply heat packs to the radiation site.
• C. Provide a diet low in carbohydrates.
• D. Avoid exposure to direct sunlight during treatment.

Correct answer: D

Rationale: The correct intervention for a client receiving radiation therapy to the head and neck is to avoid exposure to direct sunlight. Direct sunlight should be avoided to protect the skin from further irritation and damage caused by the radiation therapy. Instructing the client to use an alcohol-free mouthwash is important to prevent irritation and maintain oral hygiene, making choice A incorrect. Applying heat packs to the radiation site is contraindicated as heat can further aggravate the skin, making choice B incorrect. Providing a diet low in carbohydrates is not directly related to radiation therapy to the head and neck, so choice C is also incorrect.

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