Nursing Elites

1. The client with peripheral vascular disease is being taught by the nurse. Which interventions should the nurse discuss with the client?

• A. Keep the area between the toes dry.
• B. Wear comfortable, well-fitting shoes.
• C. Cut toenails straight across.
• D. A, B

Correct answer: D

Rationale: The correct interventions for a client with peripheral vascular disease include keeping the area between the toes dry and wearing comfortable, well-fitting shoes. Choice A is correct as moisture between the toes can lead to skin breakdown and infection. Choice B is also correct as proper footwear helps prevent injury and promotes circulation. Choice C, cutting toenails straight across, is incorrect for peripheral vascular disease clients as cutting them in an arch can reduce the risk of ingrown toenails, which is important for clients with diabetes to prevent complications. Therefore, choices A and B are the most appropriate interventions for the client with peripheral vascular disease.

2. The nurse had developed a close relationship with the family of a client who is dying. Which nursing intervention(s) are most appropriate in dealing with the family?

• A. Encouraging family discussion of feelings
• B. Accepting the family’s experience of anger
• C. Facilitating the use of spiritual practices identified by the family
• D. All of the above

Correct answer: D

Rationale: When a nurse has developed a close relationship with a dying client's family, it is crucial to provide comprehensive support. Encouraging family discussion of feelings helps them express their emotions and concerns, fostering a sense of relief. Accepting the family's experience of anger without judgment validates their emotions and promotes trust. Facilitating the use of spiritual practices identified by the family acknowledges their beliefs and values, offering comfort and solace. Therefore, all of the above interventions are essential in providing holistic care and support during such a challenging time. Choices A, B, and C each play a vital role in addressing different aspects of the family's emotional and spiritual needs, making option D the correct answer.

3. Which dietary change is most beneficial for a patient with hypertension?

• A. Increased sodium intake
• B. Decreased potassium intake
• C. Increased fiber intake
• D. Increased cholesterol intake

Correct answer: C

Rationale: The correct answer is C: Increased fiber intake. A diet high in fiber is beneficial for patients with hypertension as it helps lower blood pressure. Increased sodium intake (choice A) is not recommended as it can raise blood pressure. Decreasing potassium intake (choice B) is not advisable as potassium helps regulate blood pressure. Increased cholesterol intake (choice D) is also not recommended as high cholesterol levels can contribute to cardiovascular issues, including hypertension.

4. The client is diagnosed with hereditary spherocytosis. Which treatment/procedure would the nurse prepare the client to receive?

• A. Bone marrow transplant
• B. Splenectomy
• C. Frequent blood transfusions
• D. Liver biopsy

Correct answer: B

Rationale: The correct answer is B: Splenectomy. Splenectomy is the treatment of choice for hereditary spherocytosis. By removing the spleen, the excessive destruction of red blood cells is reduced, preventing hemolysis and improving anemia. Bone marrow transplant (A) is not a standard treatment for hereditary spherocytosis. Frequent blood transfusions (C) may temporarily address anemia but do not treat the underlying cause. Liver biopsy (D) is not indicated as a primary treatment for hereditary spherocytosis.

5. The client is diagnosed with pericarditis. When assessing the client, the nurse is unable to auscultate a friction rub. Which action should the nurse implement?

• A. Notify the healthcare provider
• B. Document that the pericarditis has resolved
• C. Ask the client to lean forward and listen again
• D. Prepare to insert a unilateral chest tube

Correct answer: C

Rationale: The correct action for the nurse to take when unable to auscultate a pericardial friction rub in a client diagnosed with pericarditis is to ask the client to lean forward and listen again. This position brings the heart closer to the chest wall, making it easier to detect a friction rub if present. Notifying the healthcare provider is not necessary at this point as it may just be a matter of positioning for better auscultation. Documenting that the pericarditis has resolved is premature without proper assessment. Preparing to insert a unilateral chest tube is not indicated based on the absence of a friction rub.

Similar Questions