Nursing Elites

1. A client in the postanesthesia care unit has an as-needed prescription for ondansetron (Zofran). Which of the following occurrences would prompt the nurse to administer this medication to the client?

• A. Paralytic ileus
• B. Incisional pain
• C. Urine retention
• D. Nausea and vomiting

Correct answer: D

Rationale: The correct answer is D: Nausea and vomiting. Ondansetron is an antiemetic used to manage postoperative nausea and vomiting, as well as nausea and vomiting related to chemotherapy. It is not indicated for treating paralytic ileus, incisional pain, or urine retention. Paralytic ileus is a condition of the gastrointestinal tract characterized by the paralysis of intestinal muscles, which would not be treated with ondansetron. Incisional pain is typically managed with analgesics, not antiemetics. Urine retention is a urinary issue that does not involve nausea and vomiting, making ondansetron an inappropriate choice for this condition.

2. The healthcare provider is assessing an older Caucasian male who has a history of peripheral vascular disease. The healthcare provider observes that the man's left great toe is black. The discoloration is probably a result of:

• A. Atrophy.
• B. Contraction.
• C. Gangrene.
• D. Rubor.

Correct answer: C

Rationale: Gangrene refers to dead, blackened tissue, often a result of chronic ischemia in clients with peripheral vascular disease. Atrophy (Choice A) is the wasting away or decrease in size of tissue or organ. Contraction (Choice B) refers to the shortening or tightening of a muscle or other body part. Rubor (Choice D) is a red discoloration of the skin, often associated with inflammation or poor circulation, but not typically presenting as blackening like gangrene.

3. A CD4+ lymphocyte count is performed on a client infected with HIV. The results of the test indicate a CD4+ count of 450 cells/L. The nurse interprets this test result as indicating:

• A. Improvement in the client
• B. The need for antiretroviral therapy
• C. The need to discontinue antiretroviral therapy
• D. An effective response to the treatment for HIV

Correct answer: B

Rationale: A CD4+ count of 450 cells/L is below the normal range (500-1600 cells/mcL), indicating a decline in immune function in the client. Antiretroviral therapy is recommended when the CD4+ count falls below 500 cells/mcL or below 25%, or when the client displays symptoms of HIV. Therefore, the interpretation of this test result suggests that the client requires antiretroviral therapy to manage the HIV infection. Choices A, C, and D are incorrect because a CD4+ count of 450 cells/L does not signify improvement, discontinuation of therapy, or an effective response to treatment for HIV.

4. The client with chronic renal failure is receiving instruction on dietary restrictions. Which of the following food items should the client be instructed to avoid?

• A. Bananas.
• B. Apples.
• C. Rice.
• D. Potatoes.

Correct answer: A

Rationale: The correct answer is A: Bananas. Bananas are high in potassium, and individuals with chronic renal failure are often advised to limit potassium intake to prevent hyperkalemia. Apples, rice, and potatoes are lower in potassium and can be included in moderation in the diet of clients with chronic renal failure.

5. A male client with chronic kidney disease (CKD) is refusing to take his medication and has missed two hemodialysis appointments. What is the best initial action for the nurse?

• A. Discuss what the treatment regimen means to him.
• B. Refer the client to a mental health nurse practitioner.
• C. Reschedule the appointments to another date and time.
• D. Discuss the option of peritoneal dialysis.

Correct answer: A

Rationale: The best initial action for the nurse in this scenario is to have a discussion with the client about what the treatment regimen means to him. It is important to assess the client's anxiety, coping styles, and acceptance of the required treatment for CKD. The client may be in denial of the diagnosis or may have concerns that need to be addressed. While rescheduling hemodialysis appointments could be helpful, referring the client to a mental health nurse practitioner or discussing peritoneal dialysis are not the most appropriate first steps. Understanding the client's perspective and concerns is crucial before exploring other interventions.

Similar Questions