Nursing Elites

1. A nurse is planning care for a client with thrombocytopenia. Which action should the nurse include in the care plan?

• A. Encourage the client to floss daily.
• B. Remove fresh flowers from the client's room.
• C. Provide the client with a stool softener.
• D. Avoid serving raw vegetables.

Correct answer: C

Rationale: The correct action the nurse should include in the care plan for a client with thrombocytopenia is to provide the client with a stool softener. Thrombocytopenia is a condition characterized by a low platelet count, which can lead to increased bleeding tendencies. Providing a stool softener helps prevent constipation and straining during bowel movements, reducing the risk of bleeding. Encouraging the client to floss daily (Choice A) is important for oral hygiene but is not directly related to managing thrombocytopenia. Removing fresh flowers from the client's room (Choice B) is more related to preventing infections in immunocompromised clients. Avoiding serving raw vegetables (Choice D) is important for clients with compromised immune systems but is not specifically targeted at managing thrombocytopenia.

2. A nurse is caring for a client who is receiving continuous enteral feedings through a nasogastric tube. Which of the following actions should the nurse take?

• A. Keep the head of the bed elevated to 15 degrees.
• B. Change the feeding bag every 48 hours.
• C. Administer the feeding through a large-bore syringe.
• D. Flush the tube with 0.9% sodium chloride every 4 hours.

Correct answer: D

Rationale: The correct action the nurse should take is to flush the tube with 0.9% sodium chloride every 4 hours. This helps maintain patency and prevents clogs during enteral feedings. Keeping the head of the bed elevated to 15 degrees (Choice A) is important for preventing aspiration but is not directly related to tube care. Changing the feeding bag every 48 hours (Choice B) is not a standard practice as the bag should be changed every 24 hours to prevent bacterial growth. Administering the feeding through a large-bore syringe (Choice C) is incorrect as enteral feedings should be given through an appropriate feeding pump for accuracy and safety.

3. When a client with schizophrenia who experiences auditory hallucinations says, 'It's hard not to listen to the voices,' which question should the nurse ask?

• A. Do you understand that the voices are not real?
• B. Why do you think the voices are talking to you?
• C. Have you tried going to a private place when this occurs?
• D. What helps you ignore what you are hearing?

Correct answer: D

Rationale: The correct question for the nurse to ask the client who experiences auditory hallucinations and finds it hard not to listen to the voices is, 'What helps you ignore what you are hearing?' This question focuses on promoting coping strategies and therapeutic communication, encouraging the client to share what techniques or interventions have been effective for managing the auditory hallucinations. Choice A is incorrect because it assumes the client does not understand that the voices are not real, which may not be the case. Choice B delves into the reasons behind the voices, which may not be immediately helpful in managing the current situation. Choice C suggests a physical solution of going to a private place, which may not address the underlying issue of coping with the voices.

4. A nurse is providing teaching to a client who has a new prescription for prednisone. Which of the following instructions should the nurse include?

• A. Take this medication on an empty stomach.
• B. Take this medication in the evening.
• C. You should avoid taking this medication with dairy products.
• D. You should monitor for signs of infection while taking this medication.

Correct answer: D

Rationale: The correct answer is D: "You should monitor for signs of infection while taking this medication." When a client is prescribed prednisone, it is essential to monitor for signs of infection due to the immunosuppressive effects of corticosteroids. Choices A, B, and C are incorrect because prednisone does not need to be taken on an empty stomach, at a specific time of day, or avoided with dairy products.

5. A nurse is providing discharge teaching to a client who is recovering from a myocardial infarction. Which of the following client statements indicates a need for further teaching?

• A. I will take a daily aspirin to prevent another heart attack.
• B. I should expect to experience chest pain when I exercise.
• C. I will increase my intake of saturated fats.
• D. I will participate in a cardiac rehabilitation program.

Correct answer: C

Rationale: The correct answer is C. Increasing the intake of saturated fats can raise cholesterol levels, which is not recommended after a myocardial infarction. Choices A, B, and D are all appropriate statements indicating a good understanding of post-myocardial infarction care. Taking a daily aspirin can help prevent another heart attack, experiencing chest pain with exercise is a common expectation post-myocardial infarction, and participating in a cardiac rehabilitation program is important for recovery and improving heart health.

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