Nursing Elites

1. A client receives discharge teaching on a new prescription for lisinopril. Which of the following instructions should be included?

• A. Avoid foods high in potassium.
• B. Take the medication with food.
• C. Increase your intake of salt.
• D. Take the medication at bedtime.

Correct answer: A

Rationale: The correct instruction that should be included when a client receives discharge teaching on a new prescription for lisinopril is to 'Avoid foods high in potassium.' Lisinopril, an ACE inhibitor, can lead to hyperkalemia by reducing potassium excretion. Therefore, clients taking lisinopril should be advised to avoid foods high in potassium to prevent potential complications associated with elevated potassium levels. Choices B, C, and D are incorrect because taking lisinopril with food, increasing salt intake, or taking the medication at bedtime are not specific instructions related to lisinopril therapy and may not be beneficial or necessary for the client's condition.

2. While assessing a client with fluid volume deficit, which of the following findings should the nurse expect?

• A. Bradycardia
• B. Increased skin turgor
• C. Dry mucous membranes
• D. Hypertension

Correct answer: C

Rationale: Dry mucous membranes are a classic clinical manifestation of fluid volume deficit. Dehydration leads to reduced fluid intake or excessive fluid loss, resulting in decreased moisture in the mucous membranes. Bradycardia, increased skin turgor, and hypertension are not typically associated with fluid volume deficit. Bradycardia is more commonly seen in conditions like hypothyroidism or increased intracranial pressure. Increased skin turgor is a sign of dehydration, not deficit. Hypertension is not a typical finding in fluid volume deficit.

3. A client has a tracheostomy and requires suctioning. Which of the following actions should be taken?

• A. Hyperoxygenate the client before suctioning
• B. Insert the catheter while exhalation
• C. Apply suction after inserting the catheter
• D. Limit suctioning to no more than 15 seconds

Correct answer: A

Rationale: Hyperoxygenating the client before suctioning is crucial to prevent hypoxia during the procedure. By using a manual resuscitation bag with 100% oxygen, the nurse should provide several breaths to the client to ensure sufficient oxygenation before starting suctioning. This approach helps maintain oxygen levels and decreases the risk of hypoxia, which may arise when suctioning interrupts the normal respiratory process. Choices B, C, and D are incorrect because inserting the catheter during exhalation, applying suction while inserting the catheter, and limiting suctioning to 15 seconds do not address the priority of hyperoxygenating the client to prevent hypoxia.

4. When teaching a client with a new diagnosis of diabetes mellitus about foot care, which of the following instructions should the nurse include?

• A. Soak your feet in hot water every day.
• B. Apply lotion between your toes.
• C. Inspect your feet daily.
• D. Use over-the-counter products to remove corns.

Correct answer: C

Rationale: Inspecting the feet daily is crucial for clients with diabetes mellitus to detect early signs of injury or infection promptly. This practice helps prevent serious complications such as diabetic foot ulcers. Soaking feet in hot water daily can lead to skin dryness and increase the risk of injury. Applying lotion between toes can cause moisture buildup, leading to fungal infections. Using over-the-counter products to remove corns can result in skin damage and should be done under healthcare provider supervision.

5. A healthcare provider is planning care for a client who has a pressure ulcer. Which of the following actions should the healthcare provider take?

• A. Massage the reddened area.
• B. Apply a heating pad to the area.
• C. Elevate the head of the bed to 45 degrees.
• D. Reposition the client every 2 hours.

Correct answer: D

Rationale: Repositioning the client every 2 hours is crucial in preventing pressure ulcers from worsening. This action helps relieve pressure on specific areas, improving circulation and reducing the risk of tissue damage. Massaging the reddened area can further damage the skin, applying heat can increase the risk of skin breakdown, and elevating the head of the bed to 45 degrees may not directly address the pressure ulcer prevention. Proper positioning is essential to avoid prolonged pressure on the affected areas and promote healing.

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