Nursing Elites

1. A client with a new diagnosis of hypertension is being taught about lifestyle modifications by a nurse. What dietary change should the nurse recommend?

• A. Increase sodium intake
• B. Limit alcohol consumption
• C. Eat a high-protein diet
• D. Follow a high-fat diet

Correct answer: B

Rationale: The correct answer is B: Limit alcohol consumption. When managing hypertension, it is crucial to reduce alcohol intake as it can raise blood pressure. High alcohol consumption can also interfere with the effectiveness of antihypertensive medications. Choices A, C, and D are incorrect. Increasing sodium intake (Choice A) is not recommended for hypertension as it can lead to fluid retention and elevated blood pressure. Eating a high-protein diet (Choice C) or following a high-fat diet (Choice D) are also not ideal for managing hypertension, as they can have negative impacts on cardiovascular health.

2. A nurse working in a mental health facility observes a client who has bipolar disorder walk over to a table occupied by other clients and knock their game off the table. Which of the following is an appropriate response by the nurse?

• A. Apologize to the others for your behavior.
• B. I am disappointed that you continue to act out when you are angry.
• C. Come outside with me for a walk.
• D. If you don't calm down, you will have to go into seclusion.

Correct answer: C

Rationale: Offering to go for a walk with the client helps redirect their energy in a non-confrontational way, avoiding escalation of aggressive behavior while promoting de-escalation.

3. A healthcare professional is reviewing the results of an ABG performed on a client with chronic emphysema. Which of the following results suggests the need for further treatment?

• A. PaO2 level of 89 mm Hg
• B. PaCO2 level of 55 mm Hg
• C. HCO3 level of 25 mEq/L
• D. pH level of 7.37

Correct answer: B

Rationale: A PaCO2 level of 55 mm Hg indicates hypercapnia, which is common in clients with emphysema but may require further treatment if it leads to respiratory acidosis or distress. Elevated PaCO2 levels can indicate inadequate ventilation and impaired gas exchange, potentially leading to respiratory acidosis. The other results fall within normal ranges or compensated values for a client with chronic emphysema and do not necessarily indicate the need for immediate intervention.

4. A nurse is caring for an older adult patient who is disoriented and has a history of falls. What actions should the nurse take?

• A. Place the bed in the lowest position, instruct the patient to remain in bed, ensure the bedside table is within reach.
• B. Instruct the patient to use the call light, apply an ambulation alarm to the patient’s leg, check on the patient hourly.
• C. Assign a sitter to monitor the patient, raise the bed rails, provide the patient with a call button.
• D. Check on the patient every two hours, provide verbal reminders to use the call light, lock the bed wheels.

Correct answer: B

Rationale: In this scenario, the correct actions for the nurse to take involve ensuring patient safety and fall prevention measures. Choice B is the correct answer because instructing the patient to use the call light allows them to signal for help, applying an ambulation alarm helps detect movement, and checking on the patient hourly increases monitoring frequency. These actions are essential for preventing falls in a disoriented patient with a history of falls. Choices A, C, and D are incorrect: A does not provide adequate monitoring or fall prevention measures, C relies solely on assigning a sitter without utilizing technological aids, and D lacks continuous monitoring and specific fall prevention strategies.

5. A client has been prescribed lithium for bipolar disorder. Which of the following should the nurse teach the client to monitor for signs of toxicity?

• A. Nausea and vomiting
• B. Increased urination
• C. Tremors
• D. Blurred vision

Correct answer: C

Rationale: The correct answer is C: Tremors. Lithium toxicity can present with symptoms such as tremors, nausea, and blurred vision. Tremors are a common early sign of lithium toxicity and should be monitored closely. While nausea and vomiting can also occur with lithium toxicity, tremors are more specific to lithium toxicity. Increased urination is not typically associated with lithium toxicity, and blurred vision is less common compared to tremors in this context.

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