Nursing Elites

1. A client with heart failure is being taught about dietary modifications by a nurse. Which of the following client statements indicates an understanding of the teaching?

• A. I will increase my intake of canned vegetables.
• B. I will limit my daily sodium intake to 2 grams.
• C. I will increase my intake of whole grains.
• D. I will reduce my intake of processed meats.

Correct answer: D

Rationale: The correct answer is 'D: I will reduce my intake of processed meats.' This choice indicates an understanding of the teaching because processed meats are high in sodium, which can worsen heart failure due to fluid retention. Choices A, B, and C do not directly address the issue of reducing sodium intake, which is crucial for clients with heart failure. Increasing canned vegetable intake (A) may not always be advisable due to potential high sodium content in canned products. Limiting sodium intake to 2 grams daily (B) is a good practice, but it's more specific to sodium restriction rather than addressing the source of sodium like processed meats. Increasing whole grains (C) is generally beneficial but does not directly relate to reducing sodium intake in heart failure clients.

2. A nurse is caring for a client with heart failure receiving digoxin. Which of the following findings should the nurse report to the provider?

• A. Heart rate 60/min.
• B. Blood pressure 110/70 mm Hg.
• C. Serum potassium 4 mEq/L.
• D. Blood pressure 120/80 mm Hg.

Correct answer: B

Rationale: The correct answer is B. A blood pressure of 110/70 mm Hg is a finding that the nurse should report to the provider when caring for a client with heart failure receiving digoxin. Digoxin can cause hypotension, so a low blood pressure reading should be reported promptly to the provider for further evaluation and management. Choices A, C, and D are within normal ranges and would not require immediate reporting. A heart rate of 60/min is considered normal, but any further decrease should be monitored. A serum potassium level of 4 mEq/L is also within the normal range. A blood pressure of 120/80 mm Hg is typically considered normal as well.

3. A nurse is reviewing the medical record of a client who is receiving heparin to treat deep vein thrombosis (DVT). Which of the following findings should the nurse report to the provider?

• A. aPTT of 38 seconds
• B. Hemoglobin of 15 g/dL
• C. Platelet count of 80,000/mm3
• D. INR of 1.0

Correct answer: C

Rationale: A platelet count of 80,000/mm3 is below the normal range and should be reported to the provider due to the risk of bleeding. Heparin can cause a rare but serious side effect known as heparin-induced thrombocytopenia, leading to a decrease in platelet count and an increased risk of bleeding. The aPTT of 38 seconds, hemoglobin of 15 g/dL, and an INR of 1.0 are within normal ranges and not directly concerning in this scenario. Platelet count is crucial to monitor in clients receiving heparin therapy to ensure adequate clotting function and prevent bleeding complications.

4. What is the priority intervention for a patient with suspected pulmonary embolism?

• A. Administer oxygen
• B. Administer anticoagulants
• C. Administer bronchodilators
• D. Reposition the patient

Correct answer: A

Rationale: Administering oxygen is the priority intervention for a patient with suspected pulmonary embolism. Maintaining adequate oxygenation is crucial in these patients to prevent hypoxemia and support oxygen delivery to tissues. Administering anticoagulants may be necessary but is not the initial priority. Administering bronchodilators is not indicated for pulmonary embolism. Repositioning the patient does not address the immediate need for oxygenation.

5. While caring for a newborn with jaundice receiving phototherapy, what action 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 while caring for a newborn with jaundice receiving phototherapy is to ensure that the newborn wears a diaper. This is essential to prevent skin irritation during phototherapy. Feeding the infant glucose water or applying lotion are not pertinent to managing jaundice or phototherapy. Keeping the infant's head covered with a cap is also not necessary for this specific situation.

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