Nursing Elites

1. An unlicensed assistive personnel (UAP) reports a weak pulse of 44 beats per minute in a client. What action should the charge nurse implement?

• A. Have the UAP recheck the pulse and report back.
• B. Have a licensed practical nurse (LPN) assess the client for apical-radial pulse deficit.
• C. Call the healthcare provider for further instructions.
• D. Immediately call the healthcare provider and prepare for transfer to critical care.

Correct answer: B

Rationale: The correct action is to have a licensed practical nurse (LPN) assess the client for an apical-radial pulse deficit. This assessment can provide further information about the client’s cardiovascular status and help determine if further intervention is necessary. Having the UAP recheck the pulse may delay appropriate assessment and intervention. Calling the healthcare provider for further instructions may not be necessary at this point unless the LPN assessment indicates a need for it. Immediately transferring the client to critical care without further assessment is not warranted based solely on the initial report of a weak pulse.

2. The nurse is providing care for a client with severe peripheral arterial disease (PAD). The client reports a history of rest ischemia, with leg pain that occurs during the night. Which action should the nurse take in response to this finding?

• A. Elevate the legs on pillows
• B. Encourage ambulation and leg exercises
• C. Provide a heating pad for warmth
• D. Offer cold packs when the pain occurs

Correct answer: C

Rationale: Providing warmth can help dilate peripheral vessels and increase blood flow, relieving ischemic pain. In PAD, where there is already compromised blood flow, elevating the legs or applying cold therapy could worsen ischemic pain by further reducing blood flow to the extremities. Encouraging ambulation and leg exercises may be beneficial in other conditions but not suitable for clients with severe PAD experiencing rest ischemia.

3. The client is being taught to choose foods rich in potassium to prevent digitalis toxicity. Which choice indicates the client understands dietary needs?

• A. Three apricots
• B. Medium banana
• C. Naval orange
• D. Baked potato

Correct answer: D

Rationale: The correct answer is D: Baked potato. Baked potatoes are rich in potassium, which is essential in preventing digitalis toxicity by helping to maintain normal electrolyte levels. Apricots, bananas, and oranges are also sources of potassium, but a baked potato has a higher potassium content compared to the other options, making it a more effective choice for preventing digitalis toxicity.

4. A client with rheumatoid arthritis is prescribed disease-modifying antirheumatic drugs (DMARDs). What should the nurse monitor for?

• A. Monitor for signs of liver toxicity.
• B. Assess for gastrointestinal side effects, such as nausea or diarrhea.
• C. Monitor for signs of infection, such as fever or sore throat.
• D. Administer DMARDs with meals to prevent gastrointestinal upset.

Correct answer: C

Rationale: Correct Answer: Monitoring for signs of infection, such as fever or sore throat, is crucial when a client with rheumatoid arthritis is prescribed disease-modifying antirheumatic drugs (DMARDs). DMARDs can suppress the immune system, making individuals more susceptible to infections. Early detection of infections allows for prompt treatment and helps prevent complications. Choices A, B, and D are incorrect because while liver toxicity and gastrointestinal side effects are possible side effects of DMARDs, monitoring for signs of infection takes priority due to the increased risk of infections associated with these medications.

5. The nurse is providing discharge teaching to a client with newly diagnosed hypertension. Which lifestyle modification should the nurse emphasize to the client?

• A. Increase sodium intake to improve fluid balance
• B. Engage in regular physical activity
• C. Increase caffeine intake to improve energy
• D. Reduce potassium intake to lower blood pressure

Correct answer: B

Rationale: Engaging in regular physical activity is a crucial lifestyle modification for managing hypertension. Regular exercise helps improve cardiovascular health, lower blood pressure, and contribute to overall well-being. Choices A, C, and D are incorrect. Increasing sodium intake is not recommended for hypertension as it can worsen fluid retention and elevate blood pressure. Increasing caffeine intake is also not advised as it may lead to increased heart rate and blood pressure. Reducing potassium intake is not beneficial as potassium is essential for maintaining healthy blood pressure levels.

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