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. What are the nursing interventions for a patient receiving anticoagulant therapy?

• A. Monitor INR levels and check for bleeding
• B. Administer antiplatelet therapy
• C. Check for signs of DVT and provide anticoagulation
• D. Administer aspirin and monitor for bleeding

Correct answer: A

Rationale: The correct nursing intervention for a patient receiving anticoagulant therapy is to monitor INR levels and check for signs of bleeding. Monitoring the INR levels helps assess the effectiveness and safety of anticoagulant therapy, while checking for bleeding is essential due to the increased risk associated with anticoagulants. Choice B is incorrect as antiplatelet therapy is not the standard treatment for patients on anticoagulant therapy. Choice C is incorrect as providing additional anticoagulation is not a direct nursing intervention in this scenario. Choice D is incorrect because administering aspirin, an antiplatelet medication, along with anticoagulants can increase the risk of bleeding and is generally avoided.

3. What are the nursing interventions for a patient with hypokalemia?

• A. Administer potassium supplements and monitor ECG
• B. Provide a high-sodium diet and monitor for hypertension
• C. Monitor for muscle weakness and provide dietary education
• D. Administer diuretics and provide oral fluids

Correct answer: A

Rationale: The correct intervention for a patient with hypokalemia is to administer potassium supplements and monitor the ECG. Potassium supplements help correct the low potassium levels in the body, while ECG monitoring is essential to detect any cardiac arrhythmias associated with hypokalemia. Choice B is incorrect because a high-sodium diet would worsen hypokalemia by further depleting potassium levels. Choice C is incorrect as it only focuses on monitoring symptoms and providing dietary education, but does not address the immediate need to correct potassium levels. Choice D is also incorrect as administering diuretics would exacerbate hypokalemia by increasing potassium loss.

4. A client is concerned about extreme fatigue after an acute myocardial infarction. What is the best strategy the nurse can suggest to promote independence in self-care?

• A. Encourage the client to rest and let the healthcare team take over self-care tasks
• B. Instruct the client to gradually resume self-care tasks, with rest periods
• C. Assign assistive personnel to complete self-care tasks for the client
• D. Ask the client's family to assist with self-care

Correct answer: B

Rationale: The best strategy to promote independence in self-care for a client concerned about extreme fatigue after an acute myocardial infarction is to instruct the client to gradually resume self-care tasks, with rest periods. This approach allows the client to regain independence without overexerting. Choice A is incorrect because encouraging the client to rest completely and letting the healthcare team take over self-care tasks may hinder independence. Choice C is incorrect as assigning assistive personnel to complete self-care tasks does not promote the client's independence. Choice D is not the best option as the primary focus should be on empowering the client to perform self-care tasks independently.

5. A nurse is planning care for a school-age child who is 4 hr postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care?

• A. Offer small amounts of clear liquids 6 hr following surgery.
• B. Give cromolyn nebulizer solution every 6 hr.
• C. Apply a warm compress to the operative site every 4 hr.
• D. Administer analgesics on a scheduled basis for the first 24 hr.

Correct answer: D

Rationale: Administering analgesics on a scheduled basis for the first 24 hours is crucial to ensure adequate pain control in the immediate postoperative period. Choice A is incorrect because clear liquids are typically initiated gradually and advanced as tolerated but not specifically at 6 hours post-surgery. Choice B is incorrect as cromolyn nebulizer solution is not indicated for postoperative pain management in this scenario. Choice C is incorrect as applying a warm compress may not be appropriate for the operative site after appendicitis surgery and can potentially increase the risk of infection.

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