Nursing Elites

1. A nurse is reviewing the medical record of a client who has major depressive disorder and is taking tranylcypromine. Which of the following foods should the nurse instruct the client to avoid?

• A. Milk
• B. Bananas
• C. Yogurt
• D. Cured meats

Correct answer: D

Rationale: The correct answer is D: Cured meats. Cured meats contain tyramine, which can lead to a hypertensive crisis in clients taking tranylcypromine. Bananas, milk, and yogurt do not contain significant amounts of tyramine and are safe for clients taking this medication. Therefore, the nurse should instruct the client to avoid cured meats to prevent adverse effects.

2. A client has a central venous catheter. Which of the following actions should be taken to prevent an air embolism?

• A. Keep the catheter clamped when not in use
• B. Have the client perform the Valsalva maneuver while the catheter is removed
• C. Use a non-coring needle to access the catheter
• D. Flush the catheter with 0.9% sodium chloride every 24 hours

Correct answer: B

Rationale: The correct action to prevent an air embolism in a client with a central venous catheter is to have the client perform the Valsalva maneuver while the catheter is removed. This maneuver helps to close the airway and prevent air from entering the bloodstream. Keeping the catheter clamped at all times (Choice A) is not necessary and may lead to clot formation. Using a non-coring needle (Choice C) is important for accessing the catheter but does not specifically prevent air embolism. Flushing the catheter with 0.9% sodium chloride (Choice D) helps maintain patency but does not directly prevent air embolism.

3. What is the best way to manage 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 correct answer is A: Administer anticoagulants. Administering anticoagulants is crucial in managing patients with suspected DVT as it helps prevent further clot formation and reduces the risk of complications like pulmonary embolism. Choice B, applying compression stockings, is more focused on preventing DVT in high-risk patients rather than managing an established case. Encouraging ambulation, choice C, is beneficial in the prevention of DVT but is not the primary management for suspected cases. Monitoring oxygen saturation, choice D, is important in overall patient care but is not the primary intervention for suspected DVT.

4. A nurse is providing teaching to a client with asthma. Which of the following client statements indicates a need for further teaching?

• A. I should use my albuterol inhaler before I exercise.
• B. I should avoid using my inhaler more than twice a week.
• C. I should take my inhaler only when I feel short of breath.
• D. I should rinse my mouth after using my corticosteroid inhaler.

Correct answer: C

Rationale: The correct answer is C because the client stating they should only take the inhaler when feeling short of breath indicates a need for further teaching. Clients with asthma should use their inhaler as prescribed, not just when short of breath. Choices A, B, and D demonstrate good asthma management practices. Choice A indicates understanding of using the albuterol inhaler before exercise to prevent exercise-induced symptoms. Choice B mentions the importance of not overusing the inhaler, which can indicate poor asthma control. Choice D shows awareness of rinsing the mouth after using a corticosteroid inhaler to prevent oral thrush.

5. A nurse is caring for a client who is comatose and has advance directives that indicate the client does not want life-sustaining measures. The client's family wants the client to have life-sustaining measures. Which of the following actions should the nurse take?

• A. Arrange for an ethics committee meeting to address the family's concerns
• B. Support the family's decision and initiate life-sustaining measures
• C. Complete an incident report
• D. Encourage the family to contact an attorney

Correct answer: A

Rationale: In this scenario, the nurse should arrange for an ethics committee meeting to address the family's concerns while ensuring the client's wishes are respected. Choosing option A allows for a formal discussion involving healthcare professionals, family members, and possibly a legal expert to navigate the situation ethically and legally. Supporting the family's decision to initiate life-sustaining measures (option B) would disregard the client's advance directives and autonomy. Completing an incident report (option C) is not appropriate in this situation as it does not address the conflict of interest between the family's desires and the client's wishes. Encouraging the family to contact an attorney (option D) may escalate the situation unnecessarily before exploring more ethical and collaborative approaches.

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