Nursing Elites

1. During a teaching session on dietary management for heart failure, a client makes a statement. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should increase my intake of foods high in sodium.
• B. I should increase my intake of foods high in potassium.
• C. I should decrease my intake of fluids.
• D. I should decrease my intake of fiber.

Correct answer: C

Rationale: The correct answer is C because decreasing fluid intake is essential in managing fluid retention and symptoms of heart failure. Restricting fluids helps prevent excessive fluid buildup in the body, thus reducing the workload on the heart and alleviating symptoms like swelling and shortness of breath. Choices A, B, and D are incorrect. Increasing intake of foods high in sodium can exacerbate fluid retention and worsen heart failure symptoms. Increasing potassium-rich foods is beneficial for some heart conditions but not heart failure specifically. Decreasing fiber intake is not a standard recommendation for heart failure management.

2. A healthcare provider is planning care for a client who has a latex allergy. Which of the following actions should the healthcare provider include in the plan?

• A. Use latex gloves without powder.
• B. Place a sign on the client's door.
• C. Apply latex gloves before donning gloves.
• D. Avoid using latex equipment.

Correct answer: B

Rationale: Placing a sign on the client’s door is crucial in alerting healthcare providers to the client's latex allergy, helping them avoid using latex products, which can trigger an allergic reaction. This precaution can prevent accidental exposure and ensure the client's safety during care. Choices A, C, and D are incorrect. Using latex gloves without powder (Choice A) is a good practice, but the question is specifically asking about an action related to the client's latex allergy, not the healthcare provider's protection. Applying latex gloves before donning gloves (Choice C) is unnecessary and could exacerbate the client's latex allergy. Avoiding using plastic equipment (Choice D) is not related to preventing exposure to latex, which is the primary concern in this scenario.

3. In an emergency department, a provider is assessing a client with an acute head injury following a motor-vehicle crash. Which of the following findings should be prioritized?

• A. A Glasgow Coma Scale score of 13
• B. Clear fluid leaking from the nose
• C. Nausea and vomiting
• D. Anisocoria

Correct answer: B

Rationale: The priority finding is the clear fluid leaking from the nose, which could indicate a cerebrospinal fluid leak and potential brain injury. This requires immediate attention to assess for possible cerebrospinal fluid leak, which is a serious complication of head trauma and needs prompt intervention to prevent further complications. While a Glasgow Coma Scale score of 13 may indicate a mild alteration in consciousness, it is not as urgent as assessing for a cerebrospinal fluid leak. Nausea and vomiting are common symptoms after head injuries but do not take precedence over assessing for a potential cerebrospinal fluid leak. Anisocoria (unequal pupils) is also important to note but is not as urgent as identifying a possible cerebrospinal fluid leak in this scenario.

4. When teaching a client how to perform self-catheterization, which of the following instructions should be included?

• A. Use sterile gloves during the procedure.
• B. Clean the catheter with alcohol after each use.
• C. Insert the catheter 2-4 inches into the urethra.
• D. Perform the procedure every 8 hours.

Correct answer: C

Rationale: To ensure effective drainage, the catheter should be inserted 2-4 inches into the urethra. This length allows the catheter to reach the bladder, bypass the urethral sphincters, and ensure proper drainage without causing discomfort or injury. Using sterile gloves, cleaning the catheter with alcohol, and performing the procedure every 8 hours are not accurate instructions for self-catheterization.

5. A client has been prescribed enoxaparin. Which of the following instructions should the nurse include?

• A. You need to obtain routine blood tests to monitor the effects of this medication.
• B. You should administer the medication into your thigh.
• C. You should inject the medication once daily.
• D. You need to use a 1-inch needle to administer the medication.

Correct answer: C

Rationale: The correct instruction to include when educating a client prescribed enoxaparin is to inject the medication once daily. Enoxaparin is typically administered via subcutaneous injection once daily, usually in the abdomen, to prevent blood clots.

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