Nursing Elites

1. A nurse is caring for a client who has Raynaud's disease. Which action should the nurse take?

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

Correct answer: A

Rationale: The correct action for the nurse to take when caring for a client with Raynaud's disease is to provide information about stress management. Raynaud's disease is a condition where the blood vessels narrow in response to cold or stress, leading to reduced blood flow to certain areas of the body, usually the fingers and toes. Stress management helps reduce triggers for Raynaud's disease by minimizing emotional stress, which can trigger vasospasms. Choice B is incorrect as maintaining a warm temperature, rather than a cool one, is recommended for individuals with Raynaud's disease to prevent triggering vasospasms. Choice C is incorrect because epinephrine is not typically used to manage Raynaud's disease, as it can further constrict blood vessels. Choice D is incorrect as glucocorticoid steroids are not a first-line treatment for Raynaud's disease.

2. A nurse is providing discharge teaching to a client following a cholecystectomy. Which of the following instructions should the nurse include?

• A. I should avoid lifting objects heavier than 5 pounds for 1 week.
• B. I can resume my usual activities after 2 weeks.
• C. I should expect to have pain in my right shoulder.
• D. I should follow a low-protein diet for 1 week.

Correct answer: C

Rationale: The correct answer is C. Pain in the right shoulder after a cholecystectomy is common due to residual gas from the procedure. Choices A, B, and D are incorrect. It is important to avoid heavy lifting for a longer period than just 1 week to prevent complications. Resuming usual activities after 2 weeks may not be appropriate depending on the individual's recovery. Following a low-protein diet is not a standard recommendation post-cholecystectomy.

3. If a nurse administers an incorrect dose of medication, which fact related to the incident report should the nurse document in the client's medical record?

• A. Time the medication was given
• B. The client's response to the medication
• C. The dose that was administered
• D. Reason for the error

Correct answer: A

Rationale: The correct answer is to document the time the medication was given. This is essential for understanding the sequence of events surrounding the medication error. While documenting the client's response to the medication (Choice B) is important for assessing any effects, the immediate concern should be to establish a clear timeline by documenting the time of administration. Recording the dose administered (Choice C) is also important, but in the context of understanding the incident, the time factor takes precedence. The reason for the error (Choice D) should be included in the incident report but may not be the first priority when documenting in the client's medical record.

4. A client with asthma asks how to use a peak flow meter. Which of the following instructions should the nurse provide?

• A. Use the peak flow meter at the same time each day.
• B. Take a slow, deep breath and blow out as hard as you can.
• C. Keep a log of your peak flow readings.
• D. Perform the test before using any bronchodilators.

Correct answer: D

Rationale: The correct answer is to instruct the client to perform the peak flow test before using any bronchodilators. This is important because it provides the most accurate baseline measurement of lung function. Choice A is not necessarily crucial for the accuracy of the test. Choice B describes the technique for spirometry, not peak flow meter use. Choice C, while important for tracking trends, is not directly related to the accuracy of the initial measurement.

5. A nurse is caring for a client who has a new prescription for enalapril. Which of the following findings should the nurse identify as an adverse effect of the medication?

• A. Cough.
• B. Dry mouth.
• C. Urinary retention.
• D. Insomnia.

Correct answer: A

Rationale: Corrected Rationale: A persistent cough is a known adverse effect of enalapril, an ACE inhibitor. Enalapril can cause the accumulation of bradykinin, leading to a dry, persistent cough in some patients. Dry mouth (choice B) and urinary retention (choice C) are not typically associated with enalapril use. Insomnia (choice D) is also not a common adverse effect of enalapril. Therefore, the correct answer is A.

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