Nursing Elites

1. A client with cirrhosis is experiencing ascites and peripheral edema. What is the nurse's priority intervention?

• A. Administer furosemide as prescribed.
• B. Administer albumin to increase oncotic pressure.
• C. Elevate the client's legs to reduce swelling.
• D. Administer a sodium-restricted diet.

Correct answer: A

Rationale: The correct answer is A: Administer furosemide as prescribed. Administering furosemide, a loop diuretic, is the priority intervention in a client with cirrhosis experiencing ascites and peripheral edema. Furosemide helps promote diuresis and reduce fluid buildup in the body. Choice B, administering albumin to increase oncotic pressure, may be beneficial in some cases but is not the priority intervention for immediate fluid removal. Elevating the client's legs (Choice C) and administering a sodium-restricted diet (Choice D) are important aspects of managing edema and ascites but are not the priority interventions in this situation.

2. A client has been given a prescription for tetracycline HCL (Sumycin). The nurse should emphasize the client to

• A. Take the medication with food or milk
• B. Avoid prolonged sun exposure
• C. Monitor for signs of yellowing skin or eyes
• D. Expect a yellow-brown discoloration of the teeth

Correct answer: C

Rationale: The correct answer is C: 'Monitor for signs of yellowing skin or eyes.' Tetracycline can cause hepatotoxicity, leading to jaundice which may present as yellowing of the skin or eyes. This is a serious side effect that the nurse should emphasize to the client. Choice A is incorrect because tetracycline should generally be taken on an empty stomach, not with food or milk. Choice B is also incorrect as tetracycline can cause photosensitivity, but it is not directly related to yellowing skin or eyes. Choice D is incorrect because tetracycline can cause yellow-brown discoloration of the teeth, but this is usually seen in children under 8 years of age, not a common concern for adult clients.

3. A client with Parkinson's disease is prescribed levodopa/carbidopa. The nurse instructs the client to take the medication with meals. Which rationale should the nurse provide for taking the medication with food?

• A. It enhances the effectiveness of the medication
• B. It helps to improve absorption
• C. It prevents orthostatic hypotension
• D. It reduces gastrointestinal upset

Correct answer: D

Rationale: The correct answer is D: 'It reduces gastrointestinal upset.' Levodopa/carbidopa can cause nausea and other gastrointestinal side effects. Taking the medication with food can help reduce these side effects and improve the client's comfort. Choices A, B, and C are incorrect because taking the medication with food does not primarily enhance effectiveness, improve absorption, or prevent orthostatic hypotension. The main reason for advising to take the medication with meals is to minimize gastrointestinal upset.

4. A client with multiple sclerosis is experiencing fatigue. What is the nurse's priority intervention?

• A. Encourage the client to increase physical activity.
• B. Encourage the client to take rest breaks during activities.
• C. Administer a stimulant medication to reduce fatigue.
• D. Advise the client to use energy conservation techniques.

Correct answer: D

Rationale: The correct answer is D: Advise the client to use energy conservation techniques. Energy conservation techniques are crucial in managing fatigue in multiple sclerosis. These techniques involve prioritizing activities, pacing oneself, and taking rest breaks to prevent overexertion, which can exacerbate fatigue. Encouraging the client to increase physical activity (choice A) may worsen fatigue if not done with proper energy conservation. Taking rest breaks during activities (choice B) is important but falls secondary to teaching energy conservation techniques. Administering a stimulant medication to reduce fatigue (choice C) should not be the priority as non-pharmacological interventions like energy conservation should be attempted first.

5. After receiving hemodialysis, what is the nurse's priority assessment for a client with chronic kidney disease?

• A. Monitor the client's potassium level.
• B. Assess the client's blood pressure.
• C. Check the client's hemoglobin and hematocrit levels.
• D. Monitor for signs of infection.

Correct answer: A

Rationale: The correct answer is to monitor the client's potassium level. During hemodialysis, there is a risk of potassium shifting, which can lead to life-threatening arrhythmias if not properly managed. Assessing the potassium level is crucial to prevent complications. While assessing blood pressure, checking hemoglobin and hematocrit levels, and monitoring for signs of infection are important aspects of care for a client with chronic kidney disease, monitoring potassium levels takes precedence due to its immediate life-threatening potential post-dialysis.

Similar Questions