Nursing Elites

1. A client is receiving chemotherapy and develops stomatitis. Which of the following interventions should the nurse include in the client's plan of care?

• A. Apply warm compresses to the mouth
• B. Rinse mouth with alcohol-free mouthwash
• C. Increase fluid intake
• D. Clean the mouth gently with a soft toothbrush after meals

Correct answer: A

Rationale: The correct answer is to apply warm compresses to the mouth. Stomatitis is an inflammation of the mucous lining in the mouth and can be a side effect of chemotherapy. Warm compresses can help soothe the affected area and promote healing. Choice B is incorrect because alcohol-based mouthwash can further irritate the mouth. Choice C is also a good intervention as increasing fluid intake can help keep the mouth moist and promote healing. However, the most direct intervention for soothing and healing the affected area is applying warm compresses. Choice D is incorrect because using a firm toothbrush can be too harsh and cause further irritation.

2. A nurse is caring for a client receiving theophylline for chronic obstructive pulmonary disease (COPD). Which of the following client findings indicates the need for immediate intervention?

• A. Productive cough
• B. Drowsiness
• C. Vomiting
• D. Polyuria

Correct answer: D

Rationale: Polyuria is a sign of theophylline toxicity and requires immediate intervention. Theophylline toxicity can lead to serious complications, and polyuria is a concerning symptom that indicates the need for urgent medical attention. Productive cough, drowsiness, and vomiting are common side effects of theophylline but are not typically indicative of immediate life-threatening issues like polyuria in the context of theophylline toxicity.

3. A client is prescribed digoxin 0.125 mg daily for heart failure. Which of the following client reports should concern the nurse as a sign of digoxin toxicity?

• A. Increased appetite
• B. Visual disturbances
• C. Weight gain
• D. Constipation

Correct answer: B

Rationale: Visual disturbances such as blurred vision or seeing halos around lights are common signs of digoxin toxicity. Increased appetite, weight gain, and constipation are not typically associated with digoxin toxicity. Weight gain could be a sign of worsening heart failure rather than digoxin toxicity. Increased appetite and constipation are not specific signs of digoxin toxicity and are less likely to be related.

4. A nurse is caring for a client prescribed methotrexate for rheumatoid arthritis. Which of the following client history findings requires the nurse to question the administration of this medication?

• A. Osteoporosis
• B. Hypertension
• C. Peptic ulcer disease
• D. Immunosuppression

Correct answer: C

Rationale: The correct answer is C: Peptic ulcer disease. Methotrexate can exacerbate peptic ulcer disease, leading to serious complications. This finding warrants questioning the administration of methotrexate to prevent harm to the client. Choices A, B, and D are not directly contraindicated with methotrexate use. Osteoporosis, hypertension, and immunosuppression are not typically reasons to question the administration of methotrexate for rheumatoid arthritis.

5. A nurse is providing client education regarding lithium therapy. Which of the following instructions should the nurse include?

• A. Take with food to decrease nausea
• B. Avoid excessive intake of caffeinated beverages
• C. Monitor for signs of dehydration
• D. Restrict salt intake to prevent water retention

Correct answer: B

Rationale: The correct answer is B. The nurse should instruct the client to avoid excessive intake of caffeinated beverages as they can interfere with lithium levels. Option A is incorrect as lithium is usually recommended to be taken on an empty stomach. Option C is not directly related to lithium therapy. Option D is not a typical instruction for lithium therapy.

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