Nursing Elites

1. The nurse is caring for a client diagnosed with deep vein thrombosis (DVT). Which intervention should the nurse include in the client's plan of care to prevent the complication of pulmonary embolism?

• A. Encourage ambulation as tolerated.
• B. Administer anticoagulants as prescribed.
• C. Apply cold compresses to the affected area.
• D. Encourage the use of incentive spirometry.

Correct answer: B

Rationale: Administering anticoagulants as prescribed is crucial in preventing the complication of pulmonary embolism in clients with deep vein thrombosis. Anticoagulants help prevent the formation of new clots and the enlargement of existing ones, thereby reducing the risk of a pulmonary embolism. Encouraging ambulation as tolerated is beneficial for preventing complications related to immobility, but it is not the primary intervention to prevent pulmonary embolism in this case. Applying cold compresses to the affected area may help with pain and swelling but does not address the prevention of pulmonary embolism. Encouraging the use of incentive spirometry is more relevant in preventing respiratory complications such as atelectasis, not specifically pulmonary embolism.

2. An ambulatory clinic nurse is interviewing a client who is complaining of flu-like symptoms. The client suddenly develops chest pain. Which question best assists the nurse in discriminating pain caused by a non-cardiac problem?

• A. Can you describe the pain to me?
• B. Have you ever experienced this pain before?
• C. Does the pain get worse when you breathe in?
• D. Can you rate the pain on a scale of 1 to 10, with 10 being the worst?

Correct answer: C

Rationale: The correct answer is C. Pain that worsens with breathing in can indicate pleuritic chest pain, which is non-cardiac in nature. This specific question helps in differentiating non-cardiac causes from cardiac causes of chest pain, as cardiac pain typically does not worsen with breathing. Choices A, B, and D are less specific in discriminating between cardiac and non-cardiac chest pain.

3. A client with heart failure is prescribed an angiotensin-converting enzyme (ACE) inhibitor. What instruction should the nurse reinforce to the client?

• A. Take the medication at bedtime.
• B. Report a persistent dry cough.
• C. Increase potassium-rich foods in the diet.
• D. Avoid taking the medication with meals.

Correct answer: B

Rationale: The correct answer is B. A persistent dry cough is a common side effect of ACE inhibitors and should be reported to the healthcare provider. This symptom can indicate a potential issue with the medication that may require adjustment or discontinuation. Choices A, C, and D are incorrect. Taking the medication at bedtime or with meals is not a specific instruction for ACE inhibitors. Increasing potassium-rich foods in the diet is not directly related to ACE inhibitor therapy and may not be suitable for all patients.

4. The healthcare provider has reinforced dietary instructions to a client with coronary artery disease. Which statement by the client indicates an understanding of the dietary instructions?

• A. I should substitute eggs and milk for meat.
• B. I will eliminate all cholesterol and fat from my diet.
• C. I should routinely use polyunsaturated oils in my diet.
• D. I need to consider becoming a strict vegetarian.

Correct answer: C

Rationale: The correct answer is C. Using polyunsaturated oils, such as vegetable oils, can help manage cholesterol levels and reduce the risk of heart disease. This dietary change is beneficial for individuals with coronary artery disease as it promotes heart health by improving cholesterol profiles. Substituting eggs and milk for meat (Choice A) may not address the overall dietary needs for managing the condition. Completely eliminating all cholesterol and fat from the diet (Choice B) is not necessary as the body needs some healthy fats. Considering becoming a strict vegetarian (Choice D) is a personal choice and may not necessarily be required to manage coronary artery disease.

5. A client with a diagnosis of hypertension is prescribed atenolol (Tenormin). The nurse should monitor the client for which common side effect of this medication?

• A. Tachycardia
• B. Dry mouth
• C. Hypotension
• D. Increased appetite

Correct answer: C

Rationale: Corrected Rationale: Atenolol is a beta-blocker that commonly causes hypotension by lowering blood pressure. Therefore, monitoring for hypotension is crucial to prevent potential complications in the client receiving this medication. The other options are incorrect: A) Tachycardia is not a common side effect of atenolol as it typically reduces heart rate, B) Dry mouth is not a typical side effect of atenolol, and D) Increased appetite is not commonly associated with atenolol use.

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