Nursing Elites

1. A client with Raynaud's disease is being cared for by a nurse. What intervention should the nurse implement?

• A. Maintain a warm temperature in the client's room.
• B. Administer epinephrine for acute episodes.
• C. Provide information about stress management.
• D. Give glucocorticoid steroid twice a day.

Correct answer: C

Rationale: The correct intervention for a client with Raynaud's disease is to provide information about stress management. Stress can trigger Raynaud's episodes, so managing stress can help reduce the frequency and severity of the condition. Maintaining a warm temperature in the client's room (Choice A) is important to prevent vasoconstriction and worsening of symptoms. Administering epinephrine (Choice B) is not a standard treatment for Raynaud's disease. Giving glucocorticoid steroids (Choice D) is not the primary treatment for Raynaud's disease and is not typically prescribed for this condition.

2. How should a healthcare provider manage a patient with chronic heart failure?

• A. Monitor daily weight
• B. Provide fluid restriction
• C. Administer diuretics
• D. Monitor intake and output

Correct answer: A

Rationale: Corrected Rationale: Daily weight monitoring is crucial in managing patients with chronic heart failure as it helps assess fluid balance. Monitoring daily weight allows healthcare providers to detect any sudden weight gain, which could indicate fluid retention and worsening heart failure. This intervention helps in adjusting treatment plans promptly. Providing fluid restriction (Choice B) can be a part of managing heart failure but is not the primary intervention mentioned in the question. Administering diuretics (Choice C) is a treatment modality for heart failure but does not encompass the comprehensive approach to patient management. Monitoring intake and output (Choice D) is important but does not specifically address the direct assessment of fluid status as daily weight monitoring does.

3. A nurse is caring for a client who has pneumonia. Which of the following findings should the nurse report to the provider immediately?

• A. Increased appetite
• B. Productive cough with green sputum
• C. Cyanosis of the lips and nail beds
• D. Mild shortness of breath

Correct answer: C

Rationale: The correct answer is C: Cyanosis of the lips and nail beds. Cyanosis is a late sign of hypoxia and indicates severe oxygen deprivation, requiring immediate intervention in clients with pneumonia. Reporting this finding promptly is crucial to prevent further complications. Choices A, B, and D are incorrect because increased appetite, productive cough with green sputum, and mild shortness of breath are common findings in clients with pneumonia and may not require immediate intervention unless they worsen or are accompanied by other concerning symptoms.

4. A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the following laboratory values should the nurse monitor?

• A. Hemoglobin
• B. aPTT
• C. INR
• D. Platelet count

Correct answer: B

Rationale: The correct answer is B: aPTT. The activated partial thromboplastin time (aPTT) is monitored to assess the therapeutic effect of heparin and to adjust the infusion rate if needed. Monitoring hemoglobin levels (choice A) is important for assessing anemia but is not specific to heparin therapy. INR (choice C) is used to monitor the effects of warfarin, not heparin. Platelet count (choice D) is important to monitor for heparin-induced thrombocytopenia, but aPTT is the primary laboratory value used to monitor heparin therapy.

5. While caring for a newborn under phototherapy lights, which of the following is an appropriate nursing action?

• A. Ensure the eye shield is covering the eyes.
• B. Apply lotion to the exposed skin.
• C. Offer glucose water between feedings.
• D. Discontinue breastfeeding during treatment.

Correct answer: A

Rationale: The correct answer is to ensure the eye shield is covering the eyes. Protecting the newborn's eyes from exposure to direct light is crucial during phototherapy to prevent potential eye damage. Applying lotion to the exposed skin (choice B) is not recommended as it can interfere with the effectiveness of the phototherapy. Offering glucose water between feedings (choice C) is not necessary and may not be suitable for a newborn undergoing treatment. Discontinuing breastfeeding during treatment (choice D) is not recommended as breast milk provides essential nutrients and hydration for the newborn, and breastfeeding should continue unless contraindicated by a specific medical condition.

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