Nursing Elites

1. A nurse is reviewing the plan of care for a client who is receiving chemotherapy for cancer. Which of the following interventions should the nurse include to prevent infection?

• A. Encourage the client to eat high-protein foods
• B. Encourage the client to drink 2 liters of fluid daily
• C. Instruct the client to use a soft toothbrush
• D. Instruct the client to use a mouthwash containing alcohol

Correct answer: C

Rationale: The correct answer is to instruct the client to use a soft toothbrush. Using a soft toothbrush helps prevent bleeding in clients receiving chemotherapy, who are at risk for mucositis. Encouraging the client to eat high-protein foods (Choice A) is important for overall health but not directly related to preventing infection. Encouraging the client to drink 2 liters of fluid daily (Choice B) is essential for hydration but does not specifically prevent infection. Instructing the client to use a mouthwash containing alcohol (Choice D) is contraindicated as alcohol-containing mouthwashes can cause irritation and dryness in the oral mucosa, increasing the risk of infection.

2. A nurse is preparing to administer insulin to a client who has type 1 diabetes mellitus. After drawing up the medication, the nurse accidentally brushes the needle on the counter's surface. Which of the following actions should the nurse take?

• A. Prepare a new dose of insulin injection
• B. Administer the insulin as it is
• C. Wipe the needle with an alcohol swab
• D. Ask the provider for guidance

Correct answer: A

Rationale: The correct action for the nurse to take is to prepare a new dose of insulin injection. Accidentally brushing the needle on a contaminated surface can lead to infection risk. Administering the insulin as it is or just wiping the needle with an alcohol swab would not be sufficient to eliminate the risk of infection. Asking the provider for guidance is not necessary in this situation as the nurse can independently take the appropriate action to ensure patient safety.

3. A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse expect?

• A. Elevated blood glucose.
• B. Decreased urine output.
• C. Dependent edema.
• D. Jaundice.

Correct answer: C

Rationale: The correct answer is C: Dependent edema. In right-sided heart failure, the heart is unable to effectively pump blood to the lungs for oxygenation, leading to fluid accumulation in the systemic circulation. This fluid backs up in the venous system, causing increased pressure in the veins of the body, resulting in dependent edema, usually starting in the lower extremities. Elevated blood glucose (choice A) is not directly related to right-sided heart failure. Decreased urine output (choice B) may occur in conditions like acute kidney injury but is not a specific finding of right-sided heart failure. Jaundice (choice D) is more commonly associated with liver dysfunction, not typically seen in right-sided heart failure.

4. A nurse is reviewing the medical record of a client who is taking enalapril for hypertension. Which of the following findings should the nurse report to the provider?

• A. Blood pressure of 150/80 mm Hg
• B. Swelling in the legs
• C. Persistent cough
• D. Heart rate of 72 beats per minute

Correct answer: C

Rationale: The correct answer is C: Persistent cough. Enalapril is known to cause a persistent dry cough as a side effect. This adverse reaction is due to the accumulation of bradykinin in the lungs, leading to irritation and cough. The nurse should report this symptom to the provider for further evaluation and possible medication adjustment. Choices A, B, and D are not directly associated with enalapril use. While a blood pressure of 150/80 mm Hg is elevated and should be monitored, it is not a direct side effect of enalapril. Swelling in the legs and a heart rate of 72 beats per minute are also not typically related to enalapril use and should be assessed but are not the priority findings to report in this scenario.

5. A nurse is collecting data from a client who is experiencing a situational crisis following the loss of a job. The client states, 'I don't think I can go through this again.' Which of the following actions is the nurse's priority?

• A. Determine if the client is experiencing psychotic thinking
• B. Determine the client's support system
• C. Ask how the client copes with stress
• D. Assess the client's vital signs

Correct answer: A

Rationale: The priority is to determine if the client is experiencing psychotic thinking or suicidal ideation. In this situation, the nurse needs to assess if the client is having distorted thoughts or losing touch with reality, which could pose an immediate risk to the client's safety. While determining the client's support system, asking how the client copes with stress, and assessing vital signs are important aspects of care, they are not the priority when there is a concern about potential psychotic thinking or suicidal ideation.

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