Nursing Elites

1. A nurse is assessing a client who has a history of seizure disorder and is receiving phenytoin. Which of the following findings should the nurse identify as an adverse effect of the medication?

• A. Bradycardia.
• B. Ataxia.
• C. Tachycardia.
• D. Insomnia.

Correct answer: B

Rationale: The correct answer is B: Ataxia. Ataxia, which refers to uncoordinated movements, is a common adverse effect of phenytoin, a medication used to manage seizure disorders. Bradycardia (Choice A) is not typically associated with phenytoin; instead, it may cause tachycardia (Choice C) as a side effect. Insomnia (Choice D) is not a common adverse effect of phenytoin.

2. A nurse is reviewing the laboratory values of a client who has diabetic ketoacidosis (DKA). Which of the following findings should the nurse report to the provider?

• A. Potassium 4.2 mEq/L
• B. Glucose 250 mg/dL
• C. Bicarbonate 20 mEq/L
• D. Sodium 135 mEq/L

Correct answer: B

Rationale: The correct answer is B. A glucose level of 250 mg/dL indicates hyperglycemia, which is expected in DKA. However, in the context of DKA management, persistent or worsening hyperglycemia can indicate inadequate treatment response or complications, necessitating further monitoring and intervention. Potassium levels are crucial in DKA due to the risk of hypokalemia, but a level of 4.2 mEq/L is within the normal range. Bicarbonate levels are typically low in DKA, making a value of 20 mEq/L consistent with the condition. Sodium levels of 135 mEq/L are also within normal limits and not a priority for immediate reporting in the context of DKA.

3. A nurse is teaching a newly licensed nurse about using a portable oxygen system. What instruction should the nurse include?

• A. The oxygen should be kept in a storage room when not in use.
• B. Turn off the oxygen when not in use.
• C. Check the oxygen level regularly using a pulse oximeter.
• D. Never leave the oxygen running when transporting a client.

Correct answer: C

Rationale: The correct answer is to check the oxygen level regularly using a pulse oximeter. This instruction is crucial as it ensures safe and adequate oxygenation for the client. Option A is incorrect as oxygen should not be stored in a storage room but in a well-ventilated area. Option B is not ideal as oxygen should be left on unless otherwise specified by a healthcare provider. Option D is also important but not directly related to the primary instruction of monitoring oxygen levels.

4. A client has a new prescription for hydrochlorothiazide. Which of the following instructions should the nurse include?

• A. Take this medication at bedtime to prevent dizziness.
• B. Increase your intake of potassium-rich foods.
• C. Take this medication with food to prevent gastrointestinal upset.
• D. This medication can increase your blood pressure.

Correct answer: B

Rationale: The correct instruction that the nurse should include for a client prescribed hydrochlorothiazide is to increase their intake of potassium-rich foods. Hydrochlorothiazide is a diuretic that can lead to potassium depletion, so increasing potassium-rich foods helps prevent hypokalemia. Option A is incorrect because hydrochlorothiazide is usually taken in the morning to prevent diuresis at night. Option C is not necessary as hydrochlorothiazide can be taken with or without food. Option D is incorrect because hydrochlorothiazide is used to lower blood pressure, not increase it.

5. A client has had a nasogastric tube in place for 2 days. Which of the following findings indicates that the client has developed an adverse effect?

• A. Dry mucous membranes
• B. Polyuria
• C. Epistaxis
• D. Diarrhea

Correct answer: C

Rationale: The correct answer is C, 'Epistaxis.' Epistaxis (nosebleed) is a common adverse effect of prolonged nasogastric tube insertion due to irritation of the nasal mucosa. Dry mucous membranes (choice A) may indicate dehydration but are not a direct adverse effect of nasogastric tube insertion. Polyuria (choice B) is excessive urination and is not typically associated with nasogastric tube insertion. Diarrhea (choice D) is also not a common adverse effect of having a nasogastric tube in place.

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