Nursing Elites

1. A nurse is preparing to administer an IV medication to a client who reports a latex allergy. Which of the following actions should the nurse take?

• A. Place the client in a supine position.
• B. Use non-latex gloves when administering the medication.
• C. Use latex-free syringes when administering the medication.
• D. Administer the medication through a latex-free IV port.

Correct answer: D

Rationale: The correct action the nurse should take when preparing to administer an IV medication to a client with a latex allergy is to administer the medication through a latex-free IV port. This measure helps prevent allergic reactions in clients with a known latex allergy. Placing the client in a supine position (Choice A) is not directly related to preventing a latex allergy reaction. Using non-latex gloves (Choice B) is important for protecting the nurse or caregiver from latex exposure but does not prevent the client's allergic reaction. While using latex-free syringes (Choice C) is a good practice, ensuring the IV port is latex-free is more crucial in preventing an allergic response in the client.

2. A client with heart failure is receiving discharge teaching from a nurse. Which of the following client statements indicates an understanding of the teaching?

• A. I should weigh myself once a week.
• B. I should limit my fluid intake to 1 liter per day.
• C. I should report a weight gain of 2 pounds in one day.
• D. I should reduce my protein intake to prevent fluid retention.

Correct answer: C

Rationale: The correct answer is C. Reporting a sudden weight gain of 2 pounds in one day is crucial in managing heart failure because it can indicate fluid retention, a common symptom in heart failure. Option A is incorrect as weighing oneself once a week may not provide timely information about fluid retention. Option B is incorrect because fluid intake restriction is individualized and generally involves more specific guidance. Option D is incorrect as protein intake is important but reducing it solely to avoid fluid retention is not the primary focus in heart failure management.

3. A client who is postoperative following hip replacement surgery. Which of the following actions should the nurse take to prevent dislocation of the hip?

• A. Position the client's legs in adduction
• B. Place a pillow between the client's legs when turning
• C. Keep the client in a low Fowler's position
• D. Turn the client onto the affected side

Correct answer: B

Rationale: Placing a pillow between the client's legs when turning is essential to prevent hip dislocation post hip replacement surgery. This action helps maintain proper alignment of the hip joint and prevents adduction, which can lead to dislocation. Positioning the client's legs in adduction (choice A) can increase the risk of hip dislocation. Keeping the client in a low Fowler's position (choice C) or turning the client onto the affected side (choice D) does not directly address hip dislocation prevention.

4. A nurse is caring for a client who is 24 hr postpartum and is breastfeeding her newborns. The client asks the nurse to warm up seaweed soup that the client's partner brought for her. Which of the following responses should the nurse make?

• A. Does the doctor know you are eating that?
• B. Why are you eating seaweed soup?
• C. Of course I will heat that up for you.
• D. The hospital food is more nutritious.

Correct answer: C

Rationale: Respecting cultural dietary preferences enhances patient-centered care.

5. A client with a new diagnosis of hypertension is being taught about lifestyle changes by a nurse. Which of the following recommendations should the nurse include?

• A. Limit sodium intake to no more than 1,500 mg per day.
• B. Exercise for at least 150 minutes each week.
• C. Avoid all dairy products.
• D. Limit intake of all carbohydrates.

Correct answer: A

Rationale: The correct recommendation for a client with hypertension is to limit sodium intake to no more than 1,500 mg per day. This helps manage hypertension by reducing fluid retention and lowering blood pressure. Choice B is a good recommendation as well, but the primary focus for hypertension management in this scenario is limiting sodium. Choices C and D are incorrect as dairy products and carbohydrates are not directly linked to hypertension.

Similar Questions