Nursing Elites

1. The nurse is caring for a client following an acute myocardial infarction. The client is concerned that providing self-care will be difficult due to extreme fatigue. Which of the following strategies should the nurse implement to promote the client's independence?

• A. Request an occupational therapy consult to determine the need for assistive devices
• B. Assign assistive personnel to perform self-care tasks for the client
• C. Instruct the client to focus on gradually resuming self-care tasks
• D. Ask the client if a family member is available to assist with his care

Correct answer: C

Rationale: Instructing the client to focus on gradually resuming self-care tasks is the most appropriate strategy to promote independence while managing fatigue. This approach encourages the client to regain autonomy by engaging in self-care activities at their own pace. Requesting an occupational therapy consult (Choice A) may be beneficial but does not directly address the client's concern regarding fatigue and self-care. Assigning assistive personnel (Choice B) may hinder the client's independence by taking over tasks the client could potentially perform. Asking about family assistance (Choice D) does not empower the client to regain self-care abilities.

2. A client receiving chemotherapy is experiencing fatigue. Which intervention should the nurse implement to manage the client's fatigue?

• A. Encourage the client to take short naps during the day
• B. Instruct the client to remain on bedrest
• C. Provide the client with a high-calorie diet
• D. Encourage the client to increase activity levels

Correct answer: A

Rationale: The correct intervention to manage fatigue in a client receiving chemotherapy is to encourage the client to take short naps during the day. Fatigue is a common side effect of chemotherapy, and allowing the client to rest can help combat this symptom. Instructing the client to remain on bedrest (Choice B) is not recommended as it may lead to deconditioning and worsen fatigue. Providing a high-calorie diet (Choice C) may be beneficial for overall nutrition but does not directly address fatigue. Encouraging the client to increase activity levels (Choice D) may exacerbate fatigue instead of alleviating it.

3. What is the proper technique for measuring a patient's blood pressure?

• A. Place the cuff at heart level and listen for Korotkoff sounds
• B. Ensure the patient is in a seated position and inflate the cuff to 180 mmHg
• C. Use a manual sphygmomanometer and measure blood pressure on both arms
• D. Monitor pulse rate and apply pressure to the brachial artery

Correct answer: A

Rationale: The correct technique for measuring blood pressure involves placing the cuff at heart level to ensure accurate readings. Listening for Korotkoff sounds helps determine the systolic and diastolic pressures. Choice B is incorrect as inflating the cuff to 180 mmHg is excessive and can lead to inaccurate readings. Choice C is incorrect as it is unnecessary to measure blood pressure on both arms unless there is a specific medical reason to do so. Choice D is incorrect as monitoring pulse rate and applying pressure to the brachial artery are not part of the standard blood pressure measurement technique.

4. What are the nursing interventions for a patient with hypertension?

• A. Monitor blood pressure and educate the patient about lifestyle changes
• B. Administer antihypertensive medications and provide dietary education
• C. Provide regular monitoring of blood pressure and administer diuretics
• D. Provide regular blood glucose monitoring

Correct answer: A

Rationale: The correct nursing interventions for a patient with hypertension involve monitoring blood pressure and educating the patient about lifestyle changes. These interventions help in managing hypertension by keeping track of the patient's blood pressure readings and empowering them with knowledge to make lifestyle modifications such as adopting a healthy diet, regular exercise, stress management, and avoiding smoking and excessive alcohol consumption. Administering antihypertensive medications (choice B) is typically done by a healthcare provider rather than a nurse. While regular monitoring of blood pressure (choice C) is important, administering diuretics is a specific medical intervention that should be prescribed by a healthcare provider. Monitoring blood glucose (choice D) is more relevant for patients with diabetes rather than hypertension.

5. What is the correct way to assess for pitting edema?

• A. Press over the bony area for 5 seconds and release
• B. Press over the skin for 10 seconds and check for discoloration
• C. Press the area and check for the presence of rash
• D. Press the skin and assess for rebound tenderness

Correct answer: A

Rationale: The correct way to assess for pitting edema is to press over a bony area, typically the tibia, for 5 seconds and then release. This allows for the identification of pitting edema, characterized by an indentation that persists for a few seconds. Choice B is incorrect as pitting edema assessment does not involve checking for discoloration. Choice C is incorrect as the presence of a rash is not indicative of pitting edema. Choice D is incorrect as rebound tenderness is a different assessment used for abdominal conditions, not for pitting edema.

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