Nursing Elites

1. A nurse is providing discharge teaching to a client who has hypertension about monitoring blood pressure at home. Which of the following instructions should the nurse include?

• A. Use a cuff that is too loose for the arm.
• B. Place the cuff over clothing.
• C. Sit quietly for 5 minutes before measuring your blood pressure.
• D. Use the same arm for each reading.

Correct answer: C

Rationale: The correct answer is to instruct the client to sit quietly for 5 minutes before measuring their blood pressure. This allows the body to relax and stabilize, leading to a more accurate reading. Choice A is incorrect because using a cuff that is too loose can result in inaccurate readings. Choice B is incorrect as the cuff should be placed directly on the bare skin. Choice D is incorrect as using the same arm for each reading is important for consistency in monitoring, but sitting quietly before measuring is crucial for accuracy.

2. A nurse is planning care for a client who is receiving hemodialysis. Which action should the nurse include in the care plan?

• A. Withhold all medications until after dialysis.
• B. Rehydrate with dextrose 5% in water for orthostatic hypotension.
• C. Check the vascular access site for bleeding after dialysis.
• D. Give an antibiotic 30 minutes before dialysis.

Correct answer: C

Rationale: The correct action the nurse should include in the care plan for a client receiving hemodialysis is to check the vascular access site for bleeding after dialysis. This is crucial as it helps in detecting and addressing any bleeding complications that may arise from the dialysis procedure. Choice A is incorrect because medications should not be withheld unless specified by the healthcare provider. Choice B is incorrect as dextrose 5% in water is not typically used for orthostatic hypotension. Choice D is incorrect as giving an antibiotic before dialysis is not a routine practice unless specifically prescribed for a particular reason.

3. A nurse is developing a care plan for a client with Alzheimer's disease. Which of the following interventions should the nurse include?

• A. Provide reality orientation throughout the day.
• B. Limit the client's choices to prevent decision fatigue.
• C. Encourage the client to participate in group therapy.
• D. Engage the client in sensory stimulation activities.

Correct answer: A

Rationale: The correct intervention the nurse should include in the care plan for a client with Alzheimer's disease is to provide reality orientation throughout the day. Reality orientation involves helping clients with Alzheimer's disease stay connected to the present, reducing confusion and disorientation. This intervention can help the client maintain a sense of time, place, and person. Choices B, C, and D are incorrect because limiting choices may lead to frustration, group therapy may not always be suitable for clients with Alzheimer's disease, and sensory stimulation activities may not address the core issue of disorientation in Alzheimer's disease.

4. A client with chronic kidney disease is being taught about dietary modifications by a nurse. Which of the following foods should the nurse instruct the client to avoid?

• A. Grilled chicken.
• B. Fresh fruit.
• C. White bread.
• D. Cheddar cheese.

Correct answer: D

Rationale: Cheddar cheese is high in phosphorus, which should be avoided by clients with chronic kidney disease. Fresh fruit is generally a healthy choice unless the client needs to limit potassium intake. Grilled chicken is a good protein source for clients with chronic kidney disease. White bread is low in phosphorus and can be included in the diet of clients with kidney disease unless they need to watch their carbohydrate intake.

5. A nurse is caring for a client who has acute pancreatitis. Which of the following interventions should the nurse take?

• A. Encourage oral intake of clear liquids
• B. Administer an antiemetic before meals
• C. Insert a nasogastric tube for suction
• D. Place the client in a supine position

Correct answer: C

Rationale: In acute pancreatitis, the gastrointestinal tract needs to rest to reduce pancreatic enzyme secretion. Inserting a nasogastric tube for suction helps decompress the stomach and reduce stimulation of the pancreas. Encouraging oral intake of clear liquids (Choice A) or administering an antiemetic before meals (Choice B) may aggravate the condition by stimulating the pancreas. Placing the client in a supine position (Choice D) may not directly address the underlying issue of reducing pancreatic stimulation.

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