Nursing Elites

1. A client with bipolar disorder is prescribed lithium. What should the nurse teach the client about lithium toxicity?

• A. Take the medication with meals to prevent gastrointestinal upset.
• B. Report any symptoms of nausea, vomiting, or diarrhea.
• C. Monitor lithium levels regularly and maintain hydration.
• D. Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs) while on lithium.

Correct answer: D

Rationale: The correct answer is D. Clients taking lithium should avoid NSAIDs as they can increase lithium levels leading to toxicity. It is essential to monitor lithium levels regularly and maintain hydration to prevent toxicity. Reporting symptoms like nausea, vomiting, or diarrhea is important, but the key teaching point regarding lithium toxicity is to avoid NSAIDs.

2. A client with deep vein thrombosis (DVT) is prescribed anticoagulants. What should the nurse monitor closely?

• A. Monitor for signs of bleeding, such as bruising.
• B. Monitor the client’s vital signs every hour.
• C. Monitor for pain in the affected limb.
• D. Assess for signs of pulmonary embolism, such as sudden shortness of breath.

Correct answer: D

Rationale: In clients with DVT, assessing for pulmonary embolism is crucial as a clot in the lungs can be life-threatening. Sudden shortness of breath or chest pain are key signs of a pulmonary embolism. While monitoring for signs of bleeding is important due to anticoagulant therapy, the immediate concern is detecting a potential pulmonary embolism. Monitoring vital signs and pain in the affected limb are relevant aspects of care but are not as urgent as assessing for pulmonary embolism in this scenario.

3. An older adult client with gastroenteritis has been taking the antidiarrheal diphenoxylate for the past 24 hours. What finding requires the nurse to take further action?

• A. Monitor the client’s fluid intake.
• B. Obtain a stool sample for testing.
• C. Administer a laxative to clear the infection.
• D. Assess skin turgor and provide fluids.

Correct answer: D

Rationale: The correct answer is D. Assessing skin turgor is crucial as tented skin turgor indicates dehydration, which can be worsened by antidiarrheal medications like diphenoxylate. Providing fluids is essential to address dehydration in this client. Monitoring fluid intake (choice A) is important, but assessing skin turgor takes precedence in this situation. Obtaining a stool sample for testing (choice B) could be necessary for diagnostic purposes but is not the immediate priority. Administering a laxative (choice C) is contraindicated in this case as it can worsen the client's condition by further exacerbating fluid loss.

4. The healthcare provider is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for immediate action by the healthcare provider?

• A. Breath sounds are audible bilaterally
• B. Mist is visible in the T-piece
• C. Pulse oximetry of 88
• D. Client is unable to verbalize

Correct answer: C

Rationale: A pulse oximetry reading of 88 indicates hypoxia, which is a serious condition requiring immediate intervention. Adequate oxygenation is crucial for the client's well-being. Choices A and B are normal findings after endotracheal intubation. Hearing bilateral breath sounds and seeing mist in the T-piece indicate proper functioning of the endotracheal tube. While choice D may indicate an issue with speaking due to the endotracheal tube, it is not as critical as the hypoxia indicated by the low pulse oximetry reading.

5. A middle-aged woman talks to the nurse in the healthcare provider's office about uterine fibroids, also called leiomyomas or myomas. What statement by the woman indicates more education is needed?

• A. I am one out of every 4 women that get fibroids, and among women my age, between the 30s or 40s, fibroids occur more frequently.
• B. My fibroids are noncancerous tumors that grow slowly.
• C. The associated problems I have had are pelvic pressure and pain, urinary incontinence, frequent urination or urine retention, and constipation.
• D. Fibroids that cause no problems still need to be taken out.

Correct answer: D

Rationale: The correct answer is D because fibroids that do not cause symptoms do not necessarily need to be removed unless they pose other health risks. Choice A provides accurate information about the prevalence of fibroids among women of the woman's age group. Choice B correctly describes fibroids as noncancerous tumors. Choice C lists common symptoms associated with fibroids, which is relevant information. However, choice D is incorrect as fibroids that are asymptomatic or not causing problems usually do not require treatment, unless they lead to complications or health risks.

Similar Questions