Nursing Elites

1. A client who has a new prescription for lisinopril is being taught by a nurse. Which of the following client statements indicates an understanding of the teaching?

• A. I should avoid using salt substitutes while taking this medication.
• B. I should take this medication with food to prevent nausea.
• C. I should increase my intake of potassium-rich foods while taking this medication.
• D. I should limit my fluid intake while taking this medication.

Correct answer: A

Rationale: The correct answer is A. Lisinopril can increase potassium levels, so clients should avoid salt substitutes that contain potassium. Choice B is incorrect because lisinopril is usually taken on an empty stomach. Choice C is incorrect because lisinopril can lead to hyperkalemia, so increasing potassium-rich foods is not recommended. Choice D is incorrect because lisinopril can cause increased urination, so fluid intake should not be limited.

2. What is the best intervention for a patient with suspected deep vein thrombosis (DVT)?

• A. Administer anticoagulants
• B. Apply compression stockings
• C. Encourage ambulation
• D. Monitor oxygen saturation

Correct answer: A

Rationale: The best intervention for a patient with suspected deep vein thrombosis (DVT) is to administer anticoagulants. Anticoagulants help prevent further clot formation and reduce the risk of complications such as pulmonary embolism. Applying compression stockings can help manage symptoms but does not address the underlying issue of clot formation. Encouraging ambulation is beneficial for overall circulation but may not be sufficient to treat DVT. Monitoring oxygen saturation is important, but it is not the primary intervention for suspected DVT.

3. A nurse is caring for a newborn who is 1-day-old and receiving phototherapy for jaundice. Which of the following actions should the nurse take?

• A. Feed the infant 30 ml (1 oz) of glucose water every 2 hours.
• B. Keep the infant's head covered with a cap.
• C. Ensure that the newborn wears a diaper.
• D. Apply lotion to the newborn every 4 hours.

Correct answer: C

Rationale: The correct action for the nurse to take is to ensure that the newborn wears a diaper. This is important to prevent skin irritation during phototherapy. Choice A is incorrect as newborns should be breastfed or formula-fed, not given glucose water. Choice B is unnecessary and may interfere with the effectiveness of phototherapy. Choice D is inappropriate as lotions can interfere with the phototherapy and increase the risk of skin damage.

4. A nurse is caring for a client who is receiving TPN. Which of the following actions should the nurse take to prevent infection?

• A. Change the TPN tubing every 72 hours.
• B. Monitor the client's blood glucose every 4 hours.
• C. Monitor the client's urine output every 8 hours.
• D. Use sterile technique when changing the central line dressing.

Correct answer: D

Rationale: The correct answer is D: 'Use sterile technique when changing the central line dressing.' When caring for a client receiving TPN, it is crucial to maintain aseptic technique to prevent infections. Changing the central line dressing with sterile technique helps reduce the risk of introducing pathogens into the client's system. Choices A, B, and C are incorrect because changing the TPN tubing every 72 hours, monitoring blood glucose, and monitoring urine output are important aspects of care but are not directly related to preventing infection in clients receiving TPN.

5. A healthcare professional is assessing a client who has a new prescription for digoxin. Which of the following findings is the priority for the healthcare professional to report to the provider?

• A. Heart rate of 58/min
• B. Weight gain of 1 kg (2.2 lb) in 24 hours
• C. Respiratory rate of 20/min
• D. Temperature of 37.3°C (99.1°F)

Correct answer: A

Rationale: The correct answer is A. A heart rate of 58/min is indicative of bradycardia, a potential sign of digoxin toxicity, which should be reported immediately. While weight gain, respiratory rate, and temperature are important parameters to monitor, they are not as critical as identifying bradycardia in a client taking digoxin.

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