Nursing Elites

1. A client is being treated with an antidepressant for major depressive disorder. Which statement by the client indicates a need for further teaching?

• A. I know it may take several weeks before I start feeling better.
• B. I should avoid drinking alcohol while taking this medication.
• C. I will stop taking the medication as soon as I feel better.
• D. I should take the medication at the same time every day.

Correct answer: C

Rationale: Choice C indicates a need for further teaching because stopping antidepressants abruptly can lead to withdrawal symptoms. It is essential for the client to follow the healthcare provider's instructions and complete the full course of medication even if they start feeling better to prevent potential relapse or withdrawal effects.

2. The healthcare provider is planning care for a non-potty-trained child with nephrotic syndrome. Which intervention provides the best means of determining fluid retention?

• A. Weigh the child daily.
• B. Observe the lower extremities for pitting edema.
• C. Measure the child's abdominal girth weekly.
• D. Weigh the child's wet diapers.

Correct answer: A

Rationale: Daily weighing is the most accurate method to monitor fluid retention in a child with nephrotic syndrome. Changes in weight can indicate fluid retention or loss, which is crucial in managing nephrotic syndrome. Observing for pitting edema and measuring abdominal girth are also important assessments, but daily weighing provides more immediate and precise information about fluid status.

3. The patient has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan?

• A. Maintain the patient on bed rest.
• B. Auscultate lung sounds every 4 hours.
• C. Monitor for Trousseau's and Chvostek's signs.
• D. Encourage fluid intake up to 4000 mL every day.

Correct answer: D

Rationale: The correct action for the nurse to include on the care plan for a patient with a calcium level of 12.1 mg/dL is to encourage fluid intake up to 4000 mL every day. This is essential to decrease the risk for renal calculi associated with hypercalcemia. While bed rest is not necessary, ambulation is encouraged to help decrease the loss of calcium from the bone. Monitoring for Trousseau's and Chvostek's signs is more relevant when hypocalcemia is suspected. Auscultating lung sounds every shift is a routine assessment, not required every 4 hours unless there is a specific respiratory concern.

4. What is the primary action of a short-acting beta2-agonist (SABA) prescribed to a patient with an acute asthma exacerbation?

• A. Reduce inflammation
• B. Relieve bronchospasm
• C. Thin respiratory secretions
• D. Suppress cough

Correct answer: B

Rationale: The correct answer is B: Relieve bronchospasm. The primary action of short-acting beta2-agonists (SABAs) is to relieve bronchospasm. These medications are bronchodilators that work by opening the airways, making breathing easier for patients experiencing asthma exacerbations. By relieving bronchospasm, SABAs help improve airflow and alleviate symptoms of asthma such as wheezing and shortness of breath. Choices A, C, and D are incorrect because SABAs do not primarily reduce inflammation, thin respiratory secretions, or suppress cough. While these actions may be part of asthma management, the immediate goal of using a SABA during an acute exacerbation is to quickly relieve bronchospasm and improve airflow.

5. When should surgical correction of hypospadias typically occur for a newborn infant as advised by the nurse?

• A. Repair should be done within one month to prevent bladder infections.
• B. Repairs should typically be done before the child is potty-trained.
• C. Delaying the repair until school age reduces castration fears.
• D. To form a proper urethra repair, it should be done after sexual maturity.

Correct answer: B

Rationale: Surgical repair of hypospadias is recommended to be performed before the child is potty-trained to prevent complications. Early correction helps in achieving better outcomes and reduces the risk of issues related to urination and development of the genitalia.

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