Nursing Elites

1. The client with newly diagnosed hypertension is being taught about lifestyle modifications. Which recommendation should be made?

• A. Increase your intake of saturated fats.
• B. Limit your alcohol intake to two drinks per day.
• C. Engage in at least 150 minutes of moderate exercise per week.
• D. Use table salt liberally to season your food.

Correct answer: C

Rationale: Engaging in at least 150 minutes of moderate exercise per week is a key lifestyle modification recommended for individuals with hypertension. Regular exercise helps manage blood pressure, improve cardiovascular health, and overall well-being. It is important for the client to adopt a healthy lifestyle to control hypertension and reduce the risk of complications.

2. The client is receiving intravenous vancomycin. Which assessment finding should the nurse report immediately?

• A. Red man syndrome.
• B. Blood pressure of 130/80 mm Hg.
• C. Mild itching at the IV site.
• D. Nausea and vomiting.

Correct answer: A

Rationale: Red man syndrome is a severe and potentially life-threatening reaction to vancomycin characterized by flushing, rash, and hypotension. Immediate intervention is required to prevent further complications such as anaphylaxis. Therefore, the nurse should report this finding immediately to ensure prompt treatment and prevent serious adverse effects.

3. When assessing a client reporting severe pain in the right lower quadrant of the abdomen, which sign would most likely indicate appendicitis?

• A. Rebound tenderness at McBurney's point.
• B. Positive Murphy's sign.
• C. Rovsing's sign.
• D. Cullen's sign.

Correct answer: A

Rationale: Rebound tenderness at McBurney's point is a classic sign of appendicitis. This sign indicates peritoneal irritation, a common feature of appendicitis. McBurney's point is located in the right lower quadrant of the abdomen and is a focal point for assessing tenderness. Positive Murphy's sign is associated with cholecystitis, not appendicitis. Rovsing's sign is elicited by palpation of the left lower quadrant resulting in pain in the right lower quadrant, also suggestive of appendicitis. Cullen's sign is associated with acute pancreatitis and manifests as periumbilical ecchymosis.

4. The nurse is caring for a client with a history of deep vein thrombosis (DVT) who is receiving warfarin (Coumadin). Which laboratory value should the nurse monitor closely?

• A. Platelet count.
• B. Prothrombin time (PT).
• C. Hemoglobin level.
• D. White blood cell count.

Correct answer: B

Rationale: Prothrombin time (PT) is monitored to ensure therapeutic levels of warfarin and prevent bleeding complications.

5. A client with newly diagnosed type 2 diabetes is preparing for discharge. Which statement by the client indicates a need for further teaching?

• A. I will take my insulin shots only when my blood sugar is high
• B. I need to follow a balanced diet and exercise regularly
• C. I should monitor my blood sugar levels regularly
• D. I need to take my medication as prescribed by my doctor

Correct answer: A

Rationale: In type 2 diabetes, insulin therapy is typically not the first-line treatment. Patients should follow their prescribed treatment plan, which may or may not include insulin. Taking insulin shots only when blood sugar is high can lead to uncontrolled glucose levels and complications. It is important to adhere to the prescribed medication regimen to manage diabetes effectively.

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