Nursing Elites

1. A male client with heart failure calls the clinic and reports that he cannot put his shoes on because they are too tight. Which additional information should the nurse obtain?

• A. What time he took his medication?
• B. Has his weight changed in the last several days?
• C. Is he still able to tighten his belt buckle?
• D. How many hours he slept last night?

Correct answer: B

Rationale: The correct answer is B: 'Has his weight changed in the last several days?' Sudden weight gain can indicate fluid retention, which is a common symptom of worsening heart failure. The inability to put on tight shoes can be due to fluid retention leading to swelling in the feet and ankles. Choices A, C, and D do not directly address the potential fluid retention issue and are less relevant in this scenario.

2. A client with asthma is prescribed a metered-dose inhaler (MDI) with albuterol. Which instruction is essential for the nurse to provide?

• A. Use the inhaler only before bedtime
• B. Shake the inhaler well before use
• C. Exhale fully before inhaling the medication
• D. Take two puffs every hour

Correct answer: B

Rationale: The correct answer is to 'Shake the inhaler well before use.' This instruction is crucial as shaking the inhaler ensures the proper mixing of the medication, which is essential for its effective delivery. Option A is incorrect because using the inhaler only before bedtime may not provide adequate relief during the day. Option C is incorrect as exhaling fully is a good practice but not the most essential instruction. Option D is incorrect as taking two puffs every hour may exceed the recommended dosage and lead to adverse effects.

3. The nurse is caring for a client with a nasogastric tube. Which action should the nurse take to ensure proper functioning of the tube?

• A. Flush the tube with 50 mL of normal saline every 8 hours
• B. Clamp the tube when not in use
• C. Position the client in a supine position
• D. Verify tube placement by checking pH of gastric contents

Correct answer: D

Rationale: Verifying tube placement by checking the pH of gastric contents is crucial to ensure the nasogastric tube is correctly positioned in the stomach. This action helps prevent complications such as aspiration. Flushing the tube with normal saline every 8 hours is not necessary for ensuring proper functioning of the tube. Clamping the tube when not in use may lead to the build-up of gastric secretions and blockages. Positioning the client in a supine position is not directly related to ensuring the proper functioning of the nasogastric tube.

4. A client reports new onset hearing loss bilaterally after taking a medication with known ototoxic effects. Which type of hearing loss should the nurse suspect?

• A. Conductive
• B. Sensorineural
• C. Mixed
• D. Central

Correct answer: B

Rationale: The correct answer is B: Sensorineural. Ototoxic medications can lead to sensorineural hearing loss by affecting the inner ear or auditory nerve. Conductive hearing loss is related to issues in the middle or outer ear, not typically caused by ototoxic medications. Mixed hearing loss is a combination of conductive and sensorineural components. Central hearing loss is related to the central nervous system, not commonly caused by ototoxic medications. Therefore, in this case, the nurse should suspect sensorineural hearing loss.

5. When assessing an adolescent with depression, what is the most important question for the nurse to ask?

• A. What is causing your feelings of depression?
• B. Have you ever thought about suicide?
• C. What actions can we take to improve your mood?
• D. Would you like your friends to come over?

Correct answer: B

Rationale: The correct answer is B: 'Have you ever thought about suicide?' When assessing an adolescent with depression, it is crucial to ask direct questions about suicidal thoughts. This helps determine the severity of the situation, especially if the person has considered or planned to harm themselves. Choice A is not as direct and specific to suicidal ideation. Choice C focuses on improving mood rather than assessing the risk of harm. Choice D is unrelated to assessing suicidal ideation and the severity of the depression.

Similar Questions