Nursing Elites

1. A nurse is caring for a client who is being discharged home following a cerebrovascular accident. Which of the following documents should the nurse plan to include with the discharge report?

• A. List of prescribed medications
• B. Potential complications to report
• C. Family contact details
• D. Dietary restrictions

Correct answer: B

Rationale: The correct answer is B: Potential complications to report. Including potential complications in the discharge report is crucial for ensuring proper follow-up care. This information helps the client and their caregivers to be aware of warning signs that may indicate a worsening condition or the need for immediate medical attention. Choices A, C, and D are important aspects of discharge planning, but providing a list of potential complications to report takes precedence as it directly impacts the client's safety and well-being post-discharge.

2. When managing a physically assaultive client, the nurse's INITIAL priority is to

• A. Restrict the client to the room
• B. Place the client under one-to-one supervision
• C. Restore the client's self-control and prevent further loss of control
• D. Clear the immediate area of other clients to prevent harm

Correct answer: C

Rationale: When dealing with a physically assaultive client, the initial priority is to focus on restoring the client's self-control and preventing further escalation. Restricting the client to the room (choice A) may escalate the situation and is not the initial priority. Placing the client under one-to-one supervision (choice B) is important but comes after ensuring the client's self-control. Clearing the immediate area of other clients (choice D) is essential for safety but is not the initial priority when compared to restoring the client's self-control.

3. A nurse is planning care for a preschool-age child who is in the acute phase of Kawasaki disease. Which of the following interventions should the nurse include in the plan of care?

• A. Administer scheduled doses of acetaminophen every 6 hr.
• B. Monitor the child's cardiac status.
• C. Administer antibiotics via intermittent IV bolus for 24 hr.
• D. Provide stimulation with children of the same age in the playroom.

Correct answer: B

Rationale: Monitoring cardiac status is crucial during the acute phase of Kawasaki disease because of the potential for coronary artery complications. Acetaminophen may be used for fever management but is not the priority intervention. Antibiotics are not indicated as Kawasaki disease is not caused by a bacterial infection. Providing stimulation in the playroom is important for the child's emotional well-being but does not address the immediate physiological concern of cardiac monitoring.

4. When providing discharge teaching to a client with diabetes, what is the most important instruction?

• A. Check blood sugar levels once daily
• B. Administer insulin as prescribed before meals
• C. Take medication only when feeling unwell
• D. Eat carbohydrate-rich meals to stabilize blood sugar

Correct answer: B

Rationale: Administering insulin as prescribed before meals is crucial for managing diabetes. This instruction is vital as it helps the client maintain blood sugar levels within the target range. Checking blood sugar levels once daily is important but not as critical as ensuring the timely administration of insulin. Taking medication only when feeling unwell is dangerous as it may lead to uncontrolled blood sugar levels. Eating carbohydrate-rich meals may actually destabilize blood sugar levels rather than stabilizing them, making it an incorrect choice.

5. A client who has undergone vein ligation and stripping to treat varicose veins should be instructed to do which of the following activities during discharge teaching?

• A. Remain sedentary for 2-3 days
• B. Walk for 1-2 hours each day
• C. Wear compression stockings only at night
• D. Elevate legs while sitting

Correct answer: B

Rationale: The correct answer is B: 'Walk for 1-2 hours each day.' After vein ligation and stripping, walking helps promote circulation and aids in the recovery process. Option A is incorrect as remaining sedentary for 2-3 days can lead to decreased circulation and potentially increase the risk of complications. Option C is incorrect because compression stockings should typically be worn during the day to support circulation. Option D is incorrect as elevating the legs while sitting is beneficial, but walking is more effective in promoting circulation and recovery in this case.

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