Nursing Elites

1. A client with osteoarthritis is prescribed acetaminophen. What is the most important teaching the nurse should provide?

• A. Take the medication with food to improve absorption.
• B. Avoid taking other pain medications to prevent liver damage.
• C. Take acetaminophen on an empty stomach to prevent stomach upset.
• D. Monitor liver function tests regularly to detect any liver damage.

Correct answer: B

Rationale: The correct answer is B. Acetaminophen can cause liver damage if taken in excessive amounts or in combination with other medications containing acetaminophen. Clients should be advised to avoid other pain medications to prevent liver toxicity. Choice A is incorrect because acetaminophen is usually taken with or without food, not specifically on an empty stomach. Choice C is incorrect because taking acetaminophen with food can help prevent stomach upset. Choice D is incorrect because while monitoring liver function tests is important for long-term acetaminophen use, the most crucial teaching is to avoid other pain medications to prevent liver damage.

2. A client is receiving morphine for postoperative pain. What is the nurse's priority assessment?

• A. Monitor the client's respiratory rate.
• B. Monitor the client's level of consciousness.
• C. Assess the client's level of pain.
• D. Monitor the client's blood pressure.

Correct answer: A

Rationale: The correct answer is to monitor the client's respiratory rate. Morphine can cause respiratory depression, so assessing the respiratory rate is crucial to detect this potential side effect early. Monitoring the client's level of consciousness (Choice B) is important but comes after ensuring adequate breathing. Assessing the client's pain level (Choice C) is essential but not the priority when dealing with the side effects of morphine. Monitoring the client's blood pressure (Choice D) is also important but not the priority assessment when the focus is on respiratory depression.

3. The nurse prepares a discharge plan for an older adult client following cataract extraction. What instructions should the nurse provide?

• A. Avoid straining, bending, or lifting heavy objects.
• B. Limit exposure to sunlight for the first 2 weeks.
• C. Irrigate the conjunctiva with saline before applying ointment.
• D. Read without direct lighting for 6 weeks.

Correct answer: A

Rationale: The correct instruction for the nurse to provide after cataract extraction is to advise the client to avoid straining, bending, or lifting heavy objects. These activities can increase intraocular pressure, which should be minimized post-surgery to promote healing and prevent complications. Choices B, C, and D are incorrect because limiting sunlight exposure, irrigating the conjunctiva with saline, and reading without direct lighting are not primary instructions following cataract extraction.

4. A client with heart failure is prescribed digoxin and reports nausea. What is the nurse's first action?

• A. Administer an anti-nausea medication as prescribed.
• B. Assess the client's digoxin level immediately.
• C. Assess the client’s apical pulse and hold the next dose if it's below 60 bpm.
• D. Instruct the client to reduce their fluid intake.

Correct answer: B

Rationale: When a client on digoxin reports nausea, it can be a sign of digoxin toxicity. The priority action for the nurse is to assess the client's digoxin level immediately. This assessment will help determine if the nausea is related to digoxin toxicity, requiring a dosage adjustment. Administering an anti-nausea medication (Choice A) does not address the underlying issue of potential digoxin toxicity. Assessing the client's apical pulse (Choice C) is important in general digoxin monitoring but not the first action when nausea is reported. Instructing the client to reduce fluid intake (Choice D) is not the initial response to nausea in a client taking digoxin.

5. A client is admitted for first and second-degree burns on the face, neck, anterior chest, and hands. The nurse's priority should be

• A. Cover the areas with dry sterile dressings
• B. Assess for dyspnea or stridor
• C. Initiate intravenous therapy
• D. Administer pain medication

Correct answer: B

Rationale: Assessing for dyspnea or stridor is crucial as these are signs of airway compromise, which is a priority concern in burns involving the face. Burns on the face can lead to airway swelling or compromise due to airway proximity, making respiratory assessment the top priority. Covering the areas with dry sterile dressings, initiating intravenous therapy, and administering pain medication are important interventions but assessing for airway issues takes precedence in this situation.

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