Nursing Elites

1. The client with Raynaud's phenomenon is being taught by the nurse about preventing episodes. Which instruction should the nurse reinforce?

• A. Wear gloves in cold weather.
• B. Avoid caffeine and chocolate.
• C. Increase intake of vitamin C.
• D. Use a heating pad for warmth.

Correct answer: A

Rationale: The correct answer is A: 'Wear gloves in cold weather.' Wearing gloves in cold weather is essential for preventing vasoconstriction and subsequent episodes of Raynaud's phenomenon. Cold temperatures can trigger vasospasms in individuals with Raynaud's, and wearing gloves helps maintain warmth and prevent the constriction of blood vessels in the extremities, reducing the likelihood of an episode. Choices B, C, and D are incorrect because while avoiding caffeine and chocolate, increasing vitamin C intake, and using a heating pad for warmth can be beneficial for overall health, they are not specifically targeted at preventing Raynaud's phenomenon episodes triggered by cold weather.

2. The healthcare professional is caring for a client who has just returned from a cardiac catheterization. The healthcare professional should prioritize which assessment?

• A. Monitoring the client's vital signs every 4 hours
• B. Assessing the puncture site for bleeding
• C. Encouraging the client to ambulate early to prevent complications
• D. Providing the client with fluids to flush out the contrast dye

Correct answer: B

Rationale: Assessing the puncture site for bleeding is a critical assessment after a cardiac catheterization procedure. This is essential to detect and address any potential complications promptly, such as hemorrhage or hematoma formation. Monitoring vital signs, encouraging early ambulation, and providing fluids to flush out contrast dye are important aspects of post-cardiac catheterization care, but assessing the puncture site for bleeding takes precedence due to the immediate risk of complications such as severe bleeding that require immediate intervention.

3. A healthcare professional is assessing a client who has been taking digoxin. Which of the following findings should the healthcare professional report to the provider?

• A. Weight gain
• B. Dry cough
• C. Hypokalemia
• D. Bradycardia

Correct answer: D

Rationale: The correct answer is D: Bradycardia. Bradycardia is a significant finding associated with digoxin toxicity. Digoxin, a medication commonly used to treat heart conditions, can lead to bradycardia as a sign of toxicity. Bradycardia requires immediate attention and reporting to the healthcare provider for further evaluation and management to prevent serious complications. Choices A, B, and C are incorrect because weight gain, dry cough, and hypokalemia are not specific signs of digoxin toxicity. While weight gain can be a side effect of digoxin, it is not a classic sign of toxicity. Dry cough is more commonly associated with medications like ACE inhibitors, and hypokalemia can be a complication of digoxin therapy but is not a direct sign of toxicity.

4. The client's B-type natriuretic peptide (BNP) level is 691 pg/mL. Which intervention should the nurse implement when providing care for the client?

• A. Take daily weights and monitor trends.
• B. Encourage fluid intake to improve hydration.
• C. Elevate the legs above the level of the heart.
• D. Position the client supine with the head of the bed at 30 degrees.

Correct answer: A

Rationale: Elevated BNP levels are indicative of heart failure, which often causes fluid retention and weight gain. Taking daily weights and monitoring trends allows the nurse to assess for changes in fluid status. This intervention helps in evaluating the effectiveness of the treatment plan and identifying worsening heart failure symptoms early. Encouraging fluid intake (Choice B) might exacerbate fluid overload in a client with elevated BNP levels. Elevating the legs (Choice C) and positioning the client supine with the head of the bed at 30 degrees (Choice D) are interventions more suitable for clients with hypotension, not specifically indicated for managing elevated BNP levels.

5. Prior to a cardiac catheterization, what instruction should the client be reminded of?

• A. You will need to be NPO for 6 to 8 hours before the procedure.
• B. You will not be able to move around during the procedure.
• C. You will be required to lie still for several hours after the test.
• D. You will not have to drink any fluids immediately before the test.

Correct answer: A

Rationale: Being NPO (nothing by mouth) for 6 to 8 hours before a cardiac catheterization is crucial to prevent complications such as aspiration during the procedure. This helps ensure the safety and accuracy of the test results by minimizing the risk of food or liquid in the stomach interfering with the procedure. Choice B is incorrect because the client will need to lie still during the procedure to ensure its accuracy. Choice C is incorrect as the client is typically required to lie flat for a few hours after the test, not several hours. Choice D is incorrect as the client is usually not allowed to drink fluids immediately before the test to prevent complications.

Similar Questions