Nursing Elites

1. A client with hypertension is prescribed hydrochlorothiazide. What teaching should the nurse provide?

• A. Take the medication in the morning to avoid frequent urination at night.
• B. Increase fluid intake to prevent dehydration.
• C. Avoid potassium-rich foods, such as bananas and oranges.
• D. Monitor the client’s potassium levels weekly.

Correct answer: B

Rationale: The correct teaching for a client prescribed hydrochlorothiazide is to increase fluid intake to prevent dehydration. Hydrochlorothiazide is a diuretic that can lead to fluid loss and electrolyte imbalances, so adequate fluid intake is crucial. Choice A is incorrect because hydrochlorothiazide is typically taken in the morning to avoid nighttime urination. Choice C is incorrect as potassium-rich foods should not be avoided but monitored, as hydrochlorothiazide can cause potassium loss. Choice D is incorrect as potassium levels should be monitored regularly, but not necessarily weekly, unless indicated by the healthcare provider.

2. A client with cirrhosis and ascites asks about fluid restriction. What is the nurse’s best response?

• A. Increase the client's fluid intake gradually.
• B. Restrict oral fluids to 1500 ml per day.
• C. Explain the importance of following a low-sodium diet.
• D. Increase dietary protein to reduce fluid retention.

Correct answer: B

Rationale: The correct answer is B: 'Restrict oral fluids to 1500 ml per day.' In clients with cirrhosis and ascites, fluid restriction is essential to prevent fluid overload, which can worsen symptoms of liver failure. Option A is incorrect because increasing fluid intake would exacerbate the issue of fluid overload. Option C, while important, is not the best initial response to the client's question about fluid restriction. Option D is incorrect as increasing dietary protein does not directly address fluid restriction in clients with cirrhosis and ascites.

3. 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.

4. The nurse is caring for a client following a craniotomy. Which finding should the nurse report immediately?

• A. Pupils equal and reactive to light.
• B. Sudden increase in urine output.
• C. Diminished breath sounds bilaterally.
• D. Increase in blood pressure by 20 mmHg.

Correct answer: C

Rationale: The correct answer is C, 'Diminished breath sounds bilaterally.' This finding should be reported immediately as it could indicate a serious complication such as increased intracranial pressure or respiratory compromise. In a post-craniotomy client, changes in breath sounds may be a sign of developing issues that need prompt intervention. Choices A, B, and D are not as critical in the immediate post-craniotomy period. Pupils equal and reactive to light are expected findings, a sudden increase in urine output may require monitoring but not immediate reporting, and a small increase in blood pressure may not be alarming unless it is significantly high or accompanied by other concerning signs.

5. While auscultating heart sounds, the nurse hears a swishing sound. How should this sound be documented?

• A. Heart murmur.
• B. Murmur.
• C. S3 sound.
• D. S4 sound.

Correct answer: B

Rationale: The correct answer is B: 'Murmur.' A murmur is a swishing sound heard during auscultation, typically caused by turbulent blood flow through the heart or valves. Choices C and D, 'S3 sound' and 'S4 sound,' refer to specific heart sounds associated with different cardiac conditions, not the general description of a swishing sound. Choice A, 'Heart murmur,' is redundant as 'murmur' alone is sufficient to describe the swishing sound heard.

Similar Questions