Nursing Elites

1. A nurse is assessing a client who is experiencing auditory hallucinations. What question should the nurse ask?

• A. Do you understand the voices are not real?
• B. Why do you think the voices are talking to you?
• C. Have you tried going to a quiet place when this occurs?
• D. What helps you ignore the voices?

Correct answer: D

Rationale: Exploring strategies to ignore the hallucinations can help clients manage symptoms.

2. A nurse is providing discharge teaching to a client who has a new prescription for digoxin. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will take my pulse before taking this medication.
• B. I should take this medication with food to prevent nausea.
• C. I will take this medication if my heart rate is less than 60/min.
• D. I should take this medication with food if I am not feeling well.

Correct answer: A

Rationale: The correct answer is A. Taking the pulse before taking digoxin is crucial as it helps monitor the heart rate, as digoxin can cause bradycardia as a side effect. Option B is incorrect because digoxin should be taken on an empty stomach to enhance absorption. Option C is incorrect because digoxin should be held and the healthcare provider should be contacted if the heart rate is less than 60/min. Option D is incorrect because digoxin should not be taken with food due to decreased absorption.

3. A client in end-stage osteoporosis is reporting severe pain, with a respiratory rate of 14 per minute. Which of the following medications should the nurse expect to be the highest priority to administer to the client?

• A. Promethazine
• B. Hydromorphone
• C. Ketorolac
• D. Amitriptyline

Correct answer: B

Rationale: In a client with severe pain like the one described, the priority medication to administer is a potent analgesic like hydromorphone. Hydromorphone is a strong opioid pain medication that can effectively manage severe pain. Promethazine (Choice A) is an antiemetic and antihistamine, not a pain medication. Ketorolac (Choice C) is a nonsteroidal anti-inflammatory drug (NSAID) that is contraindicated in end-stage renal disease due to its potential to cause kidney damage. Amitriptyline (Choice D) is a tricyclic antidepressant used for conditions like depression and neuropathic pain, but it is not the first-line treatment for severe acute pain.

4. A client is receiving discharge teaching regarding a new prescription for warfarin. Which of the following statements by the client indicates a need for further teaching?

• A. I will eat more leafy green vegetables while taking warfarin.
• B. I will have my INR checked regularly while taking warfarin.
• C. I will avoid drinking grapefruit juice while taking warfarin.
• D. I will use a soft toothbrush while taking warfarin.

Correct answer: A

Rationale: The correct answer is A. Clients taking warfarin should avoid leafy green vegetables as they are high in vitamin K, which can reduce the effectiveness of the medication. Therefore, the statement 'I will eat more leafy green vegetables while taking warfarin' indicates a need for further teaching. Choice B is correct as regular monitoring of INR levels is necessary for clients on warfarin. Choice C is correct as grapefruit juice can interact with warfarin and should be avoided. Choice D is correct as using a soft toothbrush is recommended to prevent gum bleeding while on warfarin.

5. A nurse is assessing a client who is postoperative following a gastric bypass. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 78/min
• B. Oxygen saturation of 95%
• C. Urine output of 30 mL/hr
• D. Serosanguineous wound drainage

Correct answer: C

Rationale: In a postoperative client, a urine output of 30 mL/hr is a concerning finding as it indicates oliguria, which may suggest dehydration or kidney impairment. Adequate urine output is essential for monitoring renal function and overall fluid status. A heart rate of 78/min is within the normal range for an adult. An oxygen saturation of 95% is acceptable and indicates adequate oxygenation. Serosanguineous wound drainage is expected in the early postoperative period and is not a cause for immediate concern unless it becomes excessive or changes character.

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