Nursing Elites

1. A nurse is caring for a client who has a pulmonary embolism. The nurse should identify the effectiveness of the treatment by observing which of the following?

• A. A chest x-ray reveals increased density in all fields
• B. The client reports feeling less anxious
• C. Diminished breath sounds are auscultated bilaterally
• D. ABG results include pH 7.48, PaO2 77 mm Hg, and PaCO2 47 mm Hg

Correct answer: B

Rationale: The correct answer is B because when a client reports feeling less anxious, it suggests that the treatment for a pulmonary embolism is effective. This is a good indicator of the client's overall well-being and response to treatment. Choices A, C, and D are incorrect because a chest x-ray revealing increased density in all fields, diminished breath sounds auscultated bilaterally, and ABG results showing specific values do not directly correlate with the effectiveness of treatment for a pulmonary embolism. While these assessments are important for monitoring the client's condition, the client's subjective report of feeling less anxious provides a more direct insight into the impact of the treatment.

2. A client has had a nasogastric tube in place for 2 days. Which of the following findings indicates that the client has developed an adverse effect?

• A. Dry mucous membranes
• B. Polyuria
• C. Epistaxis
• D. Diarrhea

Correct answer: C

Rationale: The correct answer is C, 'Epistaxis.' Epistaxis (nosebleed) is a common adverse effect of prolonged nasogastric tube insertion due to irritation of the nasal mucosa. Dry mucous membranes (choice A) may indicate dehydration but are not a direct adverse effect of nasogastric tube insertion. Polyuria (choice B) is excessive urination and is not typically associated with nasogastric tube insertion. Diarrhea (choice D) is also not a common adverse effect of having a nasogastric tube in place.

3. A nurse is providing discharge teaching to a client who has a new prescription for nitroglycerin sublingual tablets. Which of the following statements should the nurse include?

• A. Take the medication with food to reduce stomach upset.
• B. Store the medication in a cool, dry place.
• C. Take one tablet every 5 minutes until the pain is relieved, up to three doses.
• D. This medication may cause drowsiness.

Correct answer: C

Rationale: The correct answer is to instruct the client to take one nitroglycerin sublingual tablet every 5 minutes until the pain is relieved, up to three doses. This dosing regimen is essential for managing angina attacks effectively. Choice A is incorrect because nitroglycerin sublingual tablets should be placed under the tongue for rapid absorption, not taken with food. Choice B is incorrect because nitroglycerin tablets should be stored in their original container at room temperature, away from moisture and heat. Choice D is incorrect because nitroglycerin typically does not cause drowsiness as a side effect.

4. A healthcare provider is providing dietary teaching to a client who has a new diagnosis of hypertension. Which of the following foods should the provider recommend?

• A. Bananas
• B. Whole grains
• C. Lean beef
• D. Canned soup

Correct answer: C

Rationale: The correct answer is lean beef because it is a good source of protein and essential nutrients. When providing dietary recommendations to clients with hypertension, it is important to focus on lean protein sources to promote a balanced diet. Bananas, although a healthy fruit, may not be the best choice due to their high potassium content, which can sometimes be a concern for individuals with hypertension. Whole grains are generally a good choice, but lean protein like beef is more suitable in this scenario. Canned soup often contains high levels of sodium, which is not recommended for individuals with hypertension.

5. A client who had a colon resection and a new ascending colostomy is receiving discharge teaching from a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. My stool will become fully formed within 3 weeks.
• B. My skin should be cleaned with alcohol before applying a new pouch.
• C. I should avoid eating popcorn and fresh pineapple.
• D. I should expect bruising around the stoma.

Correct answer: C

Rationale: The correct answer is C because avoiding popcorn and fresh pineapple helps prevent complications with an ascending colostomy. Statements A, B, and D are incorrect. Statement A is inaccurate as it takes time for bowel function to normalize after surgery. Statement B is incorrect as alcohol can be irritating to the skin; gentle soap and water are recommended for cleaning. Statement D is incorrect as bruising around the stoma is not an expected outcome of colostomy creation.

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