Nursing Elites

1. An overweight client taking warfarin (Coumadin) has dry skin due to decreased arterial blood flow. What should the nurse instruct the client to do? Select all that apply.

• A. Apply lanolin or petroleum jelly to intact skin.
• B. Follow a reduced-calorie, reduced-fat diet.
• C. Inspect the involved areas daily for new ulcerations.
• D. Instruct the client to limit activities of daily living (ADLs).

Correct answer: A

Rationale: To address dry skin and prevent chronic ulcers and infections in an overweight client on warfarin with decreased arterial blood flow, the nurse should instruct the client to apply lanolin or petroleum jelly to intact skin. This helps maintain skin integrity and moisture. Following a reduced-calorie, reduced-fat diet (Choice B) may be beneficial for weight management but is not directly related to skin care. Inspecting involved areas daily for new ulcerations (Choice C) is important for skin assessment and early intervention but does not specifically address dry skin. Instructing the client to limit activities of daily living (ADLs) (Choice D) is not necessary for addressing dry skin; in fact, promoting mobility and circulation through appropriate activities is crucial.

2. What is the most common symptom of hypoglycemia that the nurse should teach the diabetic client to recognize?

• A. Nervousness
• B. Anorexia
• C. Kussmaul's respirations
• D. Bradycardia

Correct answer: A

Rationale: Nervousness is the most common symptom of hypoglycemia. It is often accompanied by other signs such as weakness, perspiration, confusion, and palpitations. Anorexia (lack of appetite) is not a typical symptom of hypoglycemia; it is more commonly associated with hyperglycemia. Kussmaul's respirations are a deep and labored breathing pattern seen in diabetic ketoacidosis, not hypoglycemia. Bradycardia (slow heart rate) is not a typical symptom of hypoglycemia; tachycardia (fast heart rate) is more commonly associated with hypoglycemia due to the release of catecholamines in response to low blood sugar.

3. After delegating to an unlicensed assistive personnel (UAP) the task of completing a bladder scan examination for a client, the nurse evaluates the UAP’s performance. Which action by the UAP indicates the nurse must provide additional instructions when delegating this task?

• A. Selecting the female icon for all female clients and the male icon for all male clients
• B. Explaining to the client, 'This test measures the amount of urine in your bladder.'
• C. Applying ultrasound gel to the scanning head and cleaning it after use
• D. Taking at least two readings using the aiming icon to position the scanning head

Correct answer: A

Rationale: The correct answer is A because the UAP should select the female icon for women who have not had a hysterectomy to allow the scanner to subtract the volume of the uterus from readings. If a woman has had a hysterectomy, the UAP should choose the male icon. Choice B is incorrect as it is essential for the UAP to explain the procedure to the client to ensure understanding. Choice C is incorrect because applying ultrasound gel to the scanning head and cleaning it after use are appropriate actions. Choice D is incorrect as it is necessary for the UAP to take at least two readings using the aiming icon to position the scanning head accurately for an effective bladder scan examination.

4. After the administration of t-PA, what should the nurse do?

• A. Observe the client for chest pain.
• B. Monitor for fever.
• C. Review the 12-lead electrocardiogram (ECG).
• D. Auscultate breath sounds.

Correct answer: A

Rationale: After the administration of t-PA, the nurse should observe the client for chest pain. Chest pain post t-PA administration could indicate reocclusion of the coronary artery, a serious complication that requires immediate intervention. Monitoring for fever (choice B) is not specifically associated with t-PA administration. While reviewing the 12-lead ECG (choice C) is important for assessing cardiac function, it may not be the immediate priority right after t-PA administration. Auscultating breath sounds (choice D) is important for assessing respiratory status but is not the most crucial assessment following t-PA administration.

5. The client with chronic renal failure asks why a low-protein diet is necessary. Which of the following is the best response by the nurse?

• A. It reduces the workload on your kidneys.
• B. It helps prevent the buildup of waste products.
• C. It helps maintain electrolyte balance in your body.
• D. It helps prevent dehydration.

Correct answer: B

Rationale: A low-protein diet is necessary for clients with chronic renal failure to help prevent the buildup of waste products, such as urea, in the body. Choice A is incorrect as the primary reason for a low-protein diet is to manage waste product accumulation rather than reducing the workload on the kidneys. Choice C is incorrect as electrolyte balance is typically managed through dietary restrictions beyond protein intake. Choice D is incorrect as preventing dehydration is not the primary purpose of a low-protein diet in chronic renal failure.

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