Nursing Elites

1. A client with a history of seizures is prescribed phenytoin (Dilantin). What side effect should the healthcare provider report immediately?

• A. Increased appetite
• B. Dry mouth
• C. Nausea and vomiting
• D. Gingival hyperplasia

Correct answer: D

Rationale: Gingival hyperplasia is a significant side effect associated with phenytoin therapy. It is characterized by an overgrowth of gum tissue, which can lead to issues such as difficulty in speaking, eating, and maintaining proper oral hygiene. This condition can progress rapidly and may require immediate intervention by the healthcare provider to prevent further complications. Increased appetite, dry mouth, and nausea/vomiting are common side effects of various medications, but they are not as urgent or serious as gingival hyperplasia in a client taking phenytoin.

2. A client is lying on the bathroom floor after a nurse responds to a call light. Which of the following actions should the nurse take first?

• A. Check the client for injuries
• B. Move hazardous objects away from the client
• C. Notify the provider
• D. Ask the client to describe how she felt prior to the fall

Correct answer: A

Rationale: The nurse's priority in this situation is to assess the client for injuries. Checking for injuries first is crucial to determine the extent of harm caused by the fall and to provide immediate care. Moving hazardous objects can wait until the client's safety is ensured. Notifying the provider and asking the client about how she felt prior to the fall are important but are secondary to assessing for injuries in this urgent scenario. It is essential to address immediate physical needs before investigating the cause of the fall or notifying other healthcare team members.

3. A client is talking with an older adult who is contemplating retirement. The client states, 'I keep thinking about how much I enjoy my job. I’m not sure I want to retire.' Which of the following responses should the nurse make?

• A. Let’s talk about how the change in your job status will affect you.
• B. You should consider how retirement will affect your financial situation.
• C. Retirement is a big change, take your time to decide.
• D. Have you thought about what you will do after you retire?

Correct answer: A

Rationale: The correct response is to discuss how the change in job status will affect the client. This helps the client consider the emotional and psychological impact of retirement. Choice B focuses solely on the financial aspect of retirement, which may not address the client's current concerns about enjoying their job. Choice C acknowledges the decision-making process but does not actively engage the client in exploring their feelings. Choice D shifts the focus to post-retirement plans without addressing the client's current hesitation about retiring.

4. A nurse at a health department is planning strategies related to heart disease. Which of the following activities should the nurse include as part of primary prevention?

• A. Providing cholesterol screening
• B. Teaching about a healthy diet
• C. Providing information about antihypertensive medications
• D. Developing a list of cardiac rehabilitation programs

Correct answer: B

Rationale: Teaching about a healthy diet is considered a primary prevention activity. Primary prevention aims to prevent the onset of a disease or health problem. Educating individuals on healthy lifestyle choices, such as diet modification, falls under primary prevention. Providing cholesterol screening (choice A) is a secondary prevention measure aimed at early detection. Offering information about antihypertensive medications (choice C) falls under secondary prevention, focusing on controlling risk factors. Developing a list of cardiac rehabilitation programs (choice D) is part of tertiary prevention, focusing on rehabilitation and improving outcomes post-disease onset.

5. The healthcare professional is preparing to administer potassium chloride intravenously to a client with hypokalemia. Which action is most important?

• A. Monitor the client's respiratory rate
• B. Check the client's urine output
• C. Administer the potassium chloride as a rapid IV push
• D. Dilute the potassium chloride in an appropriate IV solution

Correct answer: D

Rationale: The correct answer is to dilute the potassium chloride in an appropriate IV solution. Potassium chloride should never be administered as a rapid IV push as it can lead to severe complications, including cardiac arrhythmias. Diluting the medication and administering it slowly helps reduce the risk of adverse effects. Monitoring the client's respiratory rate (Choice A) and checking urine output (Choice B) are important aspects of patient assessment but not the most crucial when administering potassium chloride. Administering potassium chloride as a rapid IV push (Choice C) is dangerous and can result in serious harm to the client.

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