Nursing Elites

1. The client with Raynaud's phenomenon would benefit most by which teaching intervention?

• A. Stop smoking
• B. Keep feet dry
• C. Reduce stress
• D. Avoid caffeine

Correct answer: A

Rationale: The correct answer is A: Stop smoking. Smoking causes vasoconstriction, worsening the symptoms of Raynaud's phenomenon. Quitting smoking is crucial in managing this condition effectively. Choices B, C, and D are not as directly related to the pathophysiology of Raynaud's phenomenon. While keeping feet dry and reducing stress can be beneficial for overall health, they are not as directly linked to managing Raynaud's phenomenon as smoking cessation.

2. Mark, 9 months old, is given oral rehydration solution because of diarrhea with some dehydration. In your follow-up visit, you observed that Mark's eyes become puffy. Which one of the following would you advise Mark's mother?

• A. continue giving ORS but more slowly
• B. show mother how much solution to give
• C. stop ORS and give plain water or milk
• D. reassess patient to determine how much ORS to give

Correct answer: A

Rationale: In this scenario, observing puffy eyes in a child being treated with oral rehydration solution may indicate fluid overload. Continuing to give ORS but more slowly is the correct course of action as it helps manage hydration without overloading fluids. Choice B is not the best option in this situation as the issue is not about the quantity of the solution, but the rate of administration. Choice C is incorrect because plain water or milk is not a suitable alternative for rehydration in cases of dehydration. Choice D is also incorrect as reassessing the patient does not directly address the issue of puffy eyes, which suggests a need to adjust the administration of ORS.

3. A client with asthma is receiving albuterol (Proventil). The nurse should monitor the client for which of the following side effects?

• A. Hypoglycemia
• B. Hyperkalemia
• C. Tachycardia
• D. Hypotension

Correct answer: C

Rationale: The correct answer is C: Tachycardia. Albuterol can cause tachycardia as a side effect due to its stimulant effect on the heart. It acts as a beta-2 adrenergic agonist, leading to increased heart rate. Hypoglycemia (choice A) is not a common side effect of albuterol. Hyperkalemia (choice B) is also not typically associated with albuterol use. Hypotension (choice D) is less likely to occur as albuterol usually causes tachycardia rather than hypotension.

4. The nurse uses the DRG (Diagnosis Related Group) manual to

• A. Classify nursing diagnoses from the client's health history
• B. Identify findings related to a medical diagnosis
• C. Determine reimbursement for a medical diagnosis
• D. Implement nursing care based on case management protocol

Correct answer: C

Rationale: The DRG manual is used to determine the reimbursement rate for medical diagnoses and treatments under the prospective payment system used by healthcare facilities. Choice A is incorrect because the DRG manual is not used to classify nursing diagnoses, but rather to group medical diagnoses for billing purposes. Choice B is incorrect as the DRG manual is not used to identify findings related to medical diagnoses, but rather to standardize payments for medical services. Choice D is incorrect as the DRG manual is not used to implement nursing care based on case management protocol, but rather to set reimbursement rates.

5. When assisting a family who fails to take action during a sick member despite suggestions, you will:

• A. explain the consequences of inaction
• B. identify the courses of action open to the family and the resources needed for each
• C. discuss the consequences of each course of action available
• D. influence the family to act on what you think is best for the situation

Correct answer: B

Rationale: When helping a family decide on actions to take, it is essential to identify the courses of action available to them and the resources needed for each. This empowers the family to make informed decisions based on their specific situation. Explaining the consequences of inaction (Choice A) may be necessary but does not provide a range of options. Discussing the consequences of each course of action (Choice C) is important but does not actively guide the family on the available actions. Influencing the family (Choice D) to act based on personal judgment undermines their autonomy and may not lead to the best outcome.

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