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 who has deep vein thrombosis. Which of the following instructions should the nurse include in the plan of care?

• A. Limit the client's fluid intake to 1500 mL per day.
• B. Avoid massaging the affected extremity to relieve pain.
• C. Do not apply cold packs to the client's affected extremity.
• D. Elevate the client's affected extremity when in bed.

Correct answer: D

Rationale: The correct answer is to elevate the client's affected extremity when in bed. Elevating the extremity helps to reduce swelling and improve venous return in clients with DVT. Limiting fluid intake to 1500 mL per day (Choice A) is not directly related to managing DVT. Massaging the affected extremity (Choice B) can dislodge a clot and lead to serious complications. Applying cold packs (Choice C) can vasoconstrict blood vessels, potentially worsening the condition by reducing blood flow.

3. A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following actions should the nurse take?

• A. Shave hairy areas of skin prior to application.
• B. Wear gloves to apply the patch to the client's skin.
• C. Apply the patch within 1 hr of removing it from the protective pouch.
• D. Remove the previous patch and place it in a tissue.

Correct answer: B

Rationale: The correct answer is to wear gloves to apply the patch to the client's skin. This action ensures that the nurse does not absorb any medication through their own skin, promoting safety. Choice A is incorrect because shaving is not necessary and could irritate the skin. Choice C is incorrect because transdermal patches should be applied immediately after removal from the protective pouch to maintain their efficacy. Choice D is incorrect because used patches should be folded and discarded safely according to facility protocols.

4. A client with asthma is being taught how to use a peak flow meter by a nurse. Which of the following instructions should the nurse include?

• A. Blow as hard as possible into the mouthpiece.
• B. Exhale quickly and forcefully after taking a deep breath.
• C. Inhale as deeply as possible and then blow into the mouthpiece.
• D. Take a deep breath and hold it for 5 seconds before exhaling.

Correct answer: B

Rationale: The correct answer is B because the client should exhale quickly and forcefully into the peak flow meter after taking a deep breath to measure peak expiratory flow. Choice A is incorrect as blowing as hard as possible may not provide an accurate reading. Choice C is incorrect because inhaling deeply before blowing can affect the results. Choice D is incorrect as holding the breath before exhaling is not part of using a peak flow meter.

5. A nurse is planning care for a client who is postoperative following abdominal surgery. Which of the following interventions should the nurse implement to prevent respiratory complications?

• A. Encourage the client to ambulate twice daily.
• B. Encourage the client to deep breathe and cough every hour.
• C. Encourage the client to use an incentive spirometer every hour.
• D. Instruct the client to avoid coughing to prevent pain.

Correct answer: C

Rationale: The correct answer is C. Encouraging the client to use an incentive spirometer every hour is crucial to prevent respiratory complications postoperatively. Incentive spirometry helps in lung expansion and prevents atelectasis, which is common after abdominal surgery. Choice A, encouraging ambulation, is important for preventing complications but does not directly address respiratory issues. Choice B, deep breathing and coughing every hour, is also beneficial but not as effective in preventing atelectasis as using an incentive spirometer. Choice D, instructing the client to avoid coughing, is incorrect as coughing helps clear secretions and prevent respiratory complications.

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