Nursing Elites

1. A client with heart failure has a new prescription for furosemide. Which of the following statements should the nurse make?

• A. Taking furosemide can cause your potassium levels to be high
• B. Eat foods that are high in sodium
• C. Rise slowly when getting out of bed
• D. Taking furosemide can cause you to be overhydrated

Correct answer: C

Rationale: Educating the client on the importance of rising slowly when getting out of bed is crucial due to the risk of orthostatic hypotension associated with furosemide use. This precaution helps prevent dizziness and falls. Options A and D are incorrect as furosemide commonly causes hypokalemia and dehydration, respectively, rather than high potassium levels or overhydration. Option B is inaccurate as clients on furosemide need to reduce sodium intake to manage fluid retention.

2. A client has a new diagnosis of tuberculosis and has been placed on a multi-medication regimen. Which of the following instructions should the nurse give the client related to ethambutol?

• A. Your urine can turn a dark orange.
• B. Watch for a change in the sclera of your eyes.
• C. Watch for any changes in vision.
• D. Take vitamin B6 daily.

Correct answer: C

Rationale: Ethambutol is associated with potential vision changes, including optic neuritis. Patients should be instructed to report any visual disturbances immediately to prevent permanent vision loss. Monitoring for changes in vision is crucial to detect any adverse effects early on and prevent serious complications.

3. A patient is admitted to the hospital with complaints of nausea, vomiting, diarrhea, and severe abdominal pain. Which of the following would immediately alert the healthcare provider that the patient has bleeding from the GI tract?

• A. Complete blood count
• B. Guaiac test
• C. Vital signs
• D. Abdominal girth

Correct answer: B

Rationale: A positive guaiac test is used to detect the presence of occult (hidden) blood in the stool, suggesting bleeding from the gastrointestinal tract. It is a rapid screening test that can provide immediate information to the healthcare provider about possible gastrointestinal bleeding in patients presenting with symptoms such as nausea, vomiting, diarrhea, and severe abdominal pain.

4. When creating a plan of care for a newly admitted client with obsessive-compulsive disorder, which of the following interventions should the nurse take?

• A. Allow the client enough time to perform rituals
• B. Give the client autonomy in scheduling activities
• C. Discourage the client from exploring irrational fears
• D. Provide negative reinforcement for ritualistic behaviors

Correct answer: A

Rationale: Individuals with obsessive-compulsive disorder often feel compelled to perform rituals to alleviate anxiety. Allowing the client enough time to perform these rituals can help reduce their anxiety levels and promote a sense of control. Providing autonomy in scheduling activities can also empower the client and enhance their sense of independence. Discouraging exploration of irrational fears may increase anxiety and worsen symptoms. Negative reinforcement for ritualistic behaviors is not recommended as it can be counterproductive and reinforce the behavior.

5. The healthcare professional is preparing to take vital signs in an alert client admitted to the hospital with dehydration secondary to vomiting and diarrhea. What is the best method used to assess the client’s temperature?

• A. Oral
• B. Axillary
• C. Radial
• D. Heat-sensitive tape

Correct answer: A

Rationale: The most accurate method for assessing temperature in an alert client is the oral method. It provides a more reliable reflection of the body's core temperature compared to axillary or radial methods. In cases of dehydration, it is important to get an accurate temperature reading to monitor the client's condition closely. Axillary temperature may be affected by environmental factors, while radial temperature measurement is not a standard method for assessing core body temperature. Heat-sensitive tape is not a recognized method for assessing body temperature in clinical practice.

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