Nursing Elites

1. The healthcare professional is collecting data on a client who was just admitted to the hospital with a diagnosis of coronary artery disease (CAD). The client reveals having been under a great deal of stress recently. What should the healthcare professional do next?

• A. Ask whether the client wants to seek counseling or therapy.
• B. Explore with the client the sources of stress in their life.
• C. Reassure the client that stress is common in today's world.
• D. Ask the client to make a list of stressors for later evaluation.

Correct answer: B

Rationale: It is important for the healthcare professional to explore the sources of stress with the client to develop an effective stress management plan tailored to the individual's specific stressors. By understanding the sources of stress, healthcare professionals can identify triggers, implement appropriate interventions, and support the client's overall well-being. Option A is not the immediate next step as exploring the sources of stress should come before suggesting counseling or therapy. Option C is dismissive of the client's feelings and does not address the need for personalized stress management. Option D delays the process by asking the client to make a list without actively engaging in a discussion to identify stressors.

2. When preparing to administer a controlled substance, which of the following actions is required?

• A. Check the client's identification bracelet.
• B. Check the client's allergy status.
• C. Have a second nurse witness disposal of the medication.
• D. Document the administration in the client's medical record.

Correct answer: C

Rationale: When administering controlled substances, it is crucial to have a second nurse witness the disposal of the medication. This measure ensures proper handling, reduces the risk of diversion, and promotes compliance with regulations regarding controlled substances. Having a second nurse witness the disposal is a safeguard to maintain accountability and prevent any potential misuse or errors during the disposal process. Checking the client's identification bracelet and allergy status are important steps in medication administration but are not specifically required for controlled substances. Documenting the administration in the client's medical record is essential but does not specifically relate to the disposal of controlled substances.

3. The nurse is preparing to administer a scheduled dose of enalapril (Vasotec) to a client with hypertension. Before administering the medication, the nurse should check which priority assessment?

• A. Heart rate
• B. Blood pressure
• C. Respiratory rate
• D. Temperature

Correct answer: B

Rationale: Before administering enalapril, an antihypertensive medication, the nurse should prioritize checking the client's blood pressure. Monitoring blood pressure helps ensure it is at an acceptable level before giving the medication, as enalapril can further lower blood pressure. This assessment is crucial in preventing potential hypotensive episodes and adverse effects associated with excessive blood pressure reduction. Heart rate, respiratory rate, and temperature are important assessments but are not the priority before administering enalapril, which primarily affects blood pressure levels.

4. The client is reinforcing teaching for peripheral artery disease (PAD). Which statement by the client indicates correct understanding?

• A. I will keep my legs elevated on pillows while resting.
• B. I will avoid crossing my legs when sitting.
• C. I will wear tight compression stockings to improve circulation.
• D. I will apply heat to my legs to relieve pain and improve circulation.

Correct answer: B

Rationale: The correct answer is B. Crossing the legs can further impede blood flow in clients with PAD, worsening symptoms. Avoiding leg crossing helps maintain adequate blood flow and reduces the risk of complications associated with peripheral artery disease. Choices A, C, and D are incorrect because elevating the legs, wearing tight compression stockings, and applying heat can exacerbate symptoms in PAD by restricting blood flow or causing potential harm.

5. A client has a new prescription for furosemide. Which of the following instructions should the nurse include?

• A. Take the medication with or without food.
• B. Monitor for signs of hypokalemia.
• C. Increase your intake of potassium-rich foods.
• D. Expect an increase in urination.

Correct answer: D

Rationale: The correct instruction to include when a client is prescribed furosemide is to expect an increase in urination. Furosemide is a diuretic that works by increasing urine production, so it is essential for the client to anticipate and understand this effect. Monitoring for signs of hypokalemia and increasing potassium-rich foods are not directly related to furosemide use. Hypokalemia is a potential side effect of furosemide, so monitoring for it is crucial. Increasing potassium-rich foods can help counteract potassium loss due to diuretic use. Taking furosemide with food is not required, as it can be taken with or without food.

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