Nursing Elites

1. What is the best strategy for managing fatigue in a client who has had an acute myocardial infarction and is concerned about self-care?

• A. Instruct the client to rest completely and avoid all self-care tasks
• B. Encourage the client to gradually resume self-care tasks with frequent rest periods
• C. Assign assistive personnel to complete all self-care tasks
• D. Ask the client's family to assist with self-care tasks

Correct answer: B

Rationale: The best strategy for managing fatigue in a client who has had an acute myocardial infarction and is concerned about self-care is to encourage the client to gradually resume self-care tasks with frequent rest periods. This approach helps the client regain independence while managing fatigue effectively. Choice A is incorrect because complete rest without any self-care tasks may hinder recovery and independence. Choice C is not the best option as it does not promote the client's independence. Choice D, while involving family support, does not empower the client to regain self-care abilities.

2. A client has developed phlebitis at the IV site. What should the nurse do immediately?

• A. Apply a warm compress over the IV site
• B. Discontinue the IV and notify the provider
• C. Monitor the site for signs of infection
• D. Administer an anti-inflammatory medication

Correct answer: B

Rationale: When a client develops phlebitis at the IV site, the immediate action the nurse should take is to discontinue the IV and notify the provider. Phlebitis is inflammation of the vein, and if left untreated, it can lead to serious complications such as infection, thrombosis, or sepsis. Removing the IV line helps prevent further irritation and infection. Applying a warm compress (Choice A) may provide some relief but does not address the root cause. Monitoring for signs of infection (Choice C) is important but not the immediate action needed to address phlebitis. Administering an anti-inflammatory medication (Choice D) may be prescribed by the provider but is not the first step in managing phlebitis.

3. What is the most important nursing action when administering IV potassium?

• A. Monitor for decreased urine output
• B. Administer via IV push
• C. Administer slowly and dilute in IV fluids
• D. Ensure the client drinks 500 mL of water before administration

Correct answer: C

Rationale: The most important nursing action when administering IV potassium is to administer it slowly and dilute it in IV fluids. This approach helps prevent irritation and hyperkalemia. Monitoring for decreased urine output (Choice A) is important but not as critical as ensuring the safe administration of IV potassium. Administering potassium via IV push (Choice B) is unsafe and can lead to adverse effects. Ensuring the client drinks water before administration (Choice D) is not directly related to the safe administration of IV potassium.

4. A client who is at 38 weeks of gestation and has a history of hepatitis C asks the nurse if she will be able to breastfeed. Which of the following responses by the nurse is appropriate?

• A. You may breastfeed unless your nipples are cracked or bleeding.
• B. You must use a breast pump to provide breast milk.
• C. You must use a nipple shield when breastfeeding.
• D. You may breastfeed after your baby develops antibodies.

Correct answer: A

Rationale: The correct response is A: 'You may breastfeed unless your nipples are cracked or bleeding.' In the case of hepatitis C, breastfeeding is generally safe unless the mother's nipples are cracked or bleeding, which could increase the risk of transmission to the baby. Choice B is incorrect as using a breast pump is not a mandatory requirement for breastfeeding with hepatitis C. Choice C is incorrect as a nipple shield is not necessary in this situation. Choice D is incorrect because the baby developing antibodies does not impact the decision to breastfeed in the context of hepatitis C.

5. The nurse is caring for an 80-year-old client with Parkinson's disease. Which of the following nursing goals is MOST realistic and appropriate in planning care for this client?

• A. Facilitate the client in returning to usual activities of daily living
• B. Maintain optimal function within the client's limitations
• C. Assist the client in preparing for a peaceful and dignified death
• D. Delay the progression of the disease process in the client

Correct answer: B

Rationale: Maintaining optimal function within the client's limitations is the most realistic and appropriate nursing goal when caring for an 80-year-old client with Parkinson's disease. This goal focuses on maximizing the client's abilities and quality of life while acknowledging the impact of the disease. Option A is less realistic as returning to usual activities may not always be achievable in the case of Parkinson's disease. Option C is not appropriate as it does not address the client's current condition and care needs. Option D is less realistic as Parkinson's disease is progressive, and delaying its progression may not be entirely feasible.

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