Nursing Elites

1. A nurse is reviewing the medical record of a client who has a history of angina and is scheduled for surgery. Which of the following findings should the nurse report to the provider?

• A. Serum potassium level of 4.2 mEq/L
• B. Blood pressure of 138/84 mm Hg
• C. Platelet count of 150,000/mm³
• D. INR of 2.0

Correct answer: D

Rationale: The correct answer is D. An INR of 2.0 is within the therapeutic range for clients receiving warfarin. It is crucial to report this finding to the provider before surgery to ensure appropriate management and potential adjustments to prevent excessive bleeding risks. Choices A, B, and C are within normal limits and do not directly impact the client's surgery preparation or risk for bleeding, so they do not require immediate reporting.

2. A nurse is assessing a client who is experiencing auditory hallucinations. What question should the nurse ask?

• A. Do you understand the voices are not real?
• B. Why do you think the voices are talking to you?
• C. Have you tried going to a quiet place when this occurs?
• D. What helps you ignore the voices?

Correct answer: D

Rationale: Exploring strategies to ignore the hallucinations can help clients manage symptoms.

3. A nurse is providing discharge teaching to a client who is recovering from a myocardial infarction. Which of the following client statements indicates a need for further teaching?

• A. I will take a daily aspirin to prevent another heart attack.
• B. I should expect to experience chest pain when I exercise.
• C. I will increase my intake of saturated fats.
• D. I will participate in a cardiac rehabilitation program.

Correct answer: C

Rationale: The correct answer is C. Increasing the intake of saturated fats can raise cholesterol levels, which is not recommended after a myocardial infarction. Choices A, B, and D are all appropriate statements indicating a good understanding of post-myocardial infarction care. Taking a daily aspirin can help prevent another heart attack, experiencing chest pain with exercise is a common expectation post-myocardial infarction, and participating in a cardiac rehabilitation program is important for recovery and improving heart health.

4. A nurse is teaching a client who has heart failure about managing fluid intake. Which of the following instructions should the nurse include?

• A. Drink 2 liters of water per day.
• B. You should restrict your fluid intake to 1 liter per day.
• C. You can drink as much fluid as you want throughout the day.
• D. Limit your fluid intake to 3 liters per day.

Correct answer: B

Rationale: The correct answer is B: "You should restrict your fluid intake to 1 liter per day." Clients with heart failure should limit their fluid intake to prevent fluid overload, which can worsen their condition. Choice A is incorrect because 2 liters of water per day may be excessive for someone with heart failure. Choice C is incorrect as unlimited fluid intake is not suitable for individuals with heart failure. Choice D is also incorrect as 3 liters per day may be too much fluid for a client with heart failure.

5. A client is starting therapy with a statin medication. Which of the following instructions should the nurse include?

• A. Take the medication on an empty stomach.
• B. Avoid consuming grapefruit juice.
• C. Increase intake of dietary fiber.
• D. Take the medication in the morning.

Correct answer: B

Rationale: The correct instruction the nurse should include is to advise the client to avoid consuming grapefruit juice when taking statin medication. Grapefruit juice can interfere with the metabolism of statins, leading to an increased risk of adverse effects. Taking the medication on an empty stomach (Choice A) or in the morning (Choice D) is not specifically necessary for statins. While increasing dietary fiber intake (Choice C) is generally beneficial for health, it is not a specific instruction related to taking statin medication.

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