Nursing Elites

1. The nurse is providing discharge teaching to a client with coronary artery disease (CAD). Which of the following statements by the client indicates a need for further teaching?

• A. I will take my medication only when I have chest pain.
• B. I will follow a heart-healthy diet and exercise regularly.
• C. I will avoid smoking and limit alcohol intake.
• D. I will contact my doctor if I experience chest pain or shortness of breath.

Correct answer: A

Rationale: The statement indicates a misunderstanding because medication for CAD should be taken as prescribed, not only when chest pain occurs.

2. A client who has heart failure is admitted with a serum potassium level of 2.9 mEq/L. Which action is most important for the nurse to implement?

• A. Administer 20 mEq of potassium chloride.
• B. Initiate continuous cardiac monitoring.
• C. Arrange a consultation with the dietitian.
• D. Educate about the side effects of diuretics.

Correct answer: B

Rationale: Hypokalemia, defined as a serum potassium level below the normal range of 3.5 to 5 mEq/L, can lead to changes in myocardial irritability and ECG waveform, potentially causing life-threatening dysrhythmias. Therefore, the priority action for the nurse is to initiate continuous cardiac monitoring to promptly detect any abnormal heart rhythms or ventricular ectopy. This monitoring is crucial for assessing the impact of potassium replacement therapy on the cardiac rhythm and ensuring the safety of the client. While administering potassium chloride is important for correcting the hypokalemia, it should occur after cardiac monitoring is in place. Consulting with a dietitian and educating about diuretic side effects are relevant aspects of care but are not the immediate priority in this situation where cardiac monitoring takes precedence for timely intervention.

3. A client with functional urinary incontinence is being taught by a nurse. Which statement should the nurse include in this client’s teaching?

• A. Clean around your catheter daily with soap and water.
• B. Wash the vaginal weights with a 10% bleach solution after each use.
• C. Informing about available operations to repair your bladder.
• D. Buy slacks with elastic waistbands that are easy to pull down.

Correct answer: D

Rationale: Functional urinary incontinence is not related to bladder issues but rather to difficulties with ambulation or accessing the toilet. The goal is to help the client manage clothing independently. Elastic waistband slacks that are easy to pull down facilitate timely access to the toilet. Choices A and B are unrelated and not applicable to functional urinary incontinence. Choice C is incorrect as surgeries to repair the bladder are not indicated for functional urinary incontinence.

4. Prior to administering tissue plasminogen activator (t-PA), the nurse should assess the client for which of the following contraindications to administering the drug?

• A. Age over 60 years.
• B. History of cerebral hemorrhage.
• C. History of heart failure.
• D. Cigarette smoking.

Correct answer: B

Rationale: The correct answer is B: History of cerebral hemorrhage. A history of cerebral hemorrhage is a contraindication to t-PA administration because of the increased risk of bleeding. Choices A, C, and D are incorrect. Age over 60 years is not a contraindication for t-PA administration. While older age may pose some risks, it is not an absolute contraindication. History of heart failure is not a direct contraindication to t-PA administration. Cigarette smoking, while a risk factor for cardiovascular disease, is not a specific contraindication for t-PA administration.

5. Healthcare workers must protect themselves against becoming infected with HIV. The Center for Disease Control has issued guidelines for healthcare workers in relation to protection from HIV. These guidelines include which recommendation?

• A. Place HIV-positive clients in strict isolation and limit visitors.
• B. Wear gloves when coming in contact with the blood or body fluids of any client.
• C. Conduct mandatory HIV testing of those who work with clients with AIDS.
• D. Freeze HIV blood specimens at -70°F to kill the virus.

Correct answer: B

Rationale: The correct answer is B. The CDC guidelines recommend that healthcare workers wear gloves when coming in contact with blood or body fluids from any client since HIV can be infectious before the client becomes aware of their exposure and/or symptomatic. Choice A is incorrect because placing HIV-positive clients in strict isolation and limiting visitors is not a standard practice for HIV infection control. Choice C is incorrect as mandatory HIV testing for those working with AIDS clients is not a CDC recommendation for routine infection control. Choice D is incorrect because freezing HIV blood specimens at -70°F does not kill the virus; HIV can remain infectious even at very low temperatures.

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