Nursing Elites

1. A nurse is providing discharge teaching for a client who has an implantable cardioverter defibrillator. Which of the following statements demonstrates understanding of the teaching?

• A. I will soak in the tub rather than showering.
• B. I will wear loose clothing around my ICD.
• C. I will stop using my microwave oven at home because of my ICD.
• D. I can hold my cellphone on the same side of my body as the ICD.

Correct answer: B

Rationale: The correct answer is B. Wearing loose clothing around the ICD is essential to avoid putting pressure on the device, which can interfere with its function. Choices A, C, and D are incorrect. Soaking in a tub rather than showering is not relevant to ICD care. Stopping the use of a microwave oven is not necessary with an ICD. Holding a cellphone on the same side as the ICD is not recommended as it can potentially interfere with the device.

2. A nurse is reviewing the laboratory results of a client who is receiving warfarin therapy for atrial fibrillation. Which of the following laboratory values should the nurse report to the provider?

• A. INR 1.8
• B. Hemoglobin 14 g/dL
• C. Platelets 175,000/mm³
• D. Potassium 3.8 mEq/L

Correct answer: A

Rationale: The correct answer is A. An INR of 1.8 is below the therapeutic range for a client receiving warfarin, indicating a potential risk of blood clots. This value should be reported to the provider for further evaluation and possible adjustment of the warfarin dosage. Choices B, C, and D are within normal ranges and do not directly relate to the effectiveness or safety of warfarin therapy in this scenario, making them less urgent to report.

3. When providing dietary teaching for a new prescription of phenelzine, which of the following foods should be avoided?

• A. Broccoli
• B. Yogurt
• C. Cream Cheese
• D. Fruit Juice

Correct answer: A

Rationale: The correct answer is A, Broccoli. Foods high in tyramine, such as broccoli, should be avoided when taking MAOIs like phenelzine to prevent a hypertensive crisis. Yogurt, cream cheese, and fruit juice do not contain significant levels of tyramine and can be safely consumed while on phenelzine.

4. A nurse is caring for a client who speaks a language different from the nurse. Which of the following actions should the nurse take?

• A. Request an interpreter of a different sex from the client
• B. Request a family member or friend to interpret information for the client
• C. Direct attention toward the interpreter when speaking to the client
• D. Review the facility policy about the use of an interpreter

Correct answer: D

Rationale: The correct action for the nurse to take when caring for a client who speaks a different language is to review the facility policy about the use of an interpreter. This ensures compliance with best practices for communication when using interpreters, maintaining accuracy and confidentiality. Requesting an interpreter of a different sex from the client (Choice A) is not relevant to effective communication. Asking a family member or friend to interpret (Choice B) can lead to misinterpretation or breach of confidentiality. Directing attention toward the interpreter (Choice C) is not as crucial as understanding the facility's policy on interpreter use.

5. A client with a history of depression and experiencing a situational crisis is being assessed by a nurse. What action should the nurse take first?

• A. Notify the client's support system.
• B. Help the client identify personal strengths.
• C. Confirm the client's perception of the event.
• D. Teach the client relaxation techniques.

Correct answer: A

Rationale: When a client with a history of depression is experiencing a situational crisis, the first action the nurse should take is to notify the client's support system. This is crucial as the client may require immediate assistance and support. While helping the client identify personal strengths and confirming the client's perception of the event are important aspects of the assessment and intervention process, notifying the support system takes priority in ensuring the client's safety and well-being. Teaching relaxation techniques may be beneficial but addressing the client's immediate crisis through support system notification is the most appropriate initial action.

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