Nursing Elites

1. A nurse is assessing a client who is receiving chemotherapy and has stomatitis. Which of the following findings should the nurse expect?

• A. Dry, cracked lips
• B. Bleeding gums
• C. Foul-smelling breath
• D. Red, open sores in the mouth

Correct answer: D

Rationale: The correct answer is D: Red, open sores in the mouth. Stomatitis, a common side effect of chemotherapy, presents with red, open sores in the mouth, which can be painful and increase the risk of infection. Choices A, B, and C are incorrect because stomatitis typically does not manifest as dry, cracked lips, bleeding gums, or foul-smelling breath.

2. A nurse is caring for a client who has an indwelling urinary catheter. What should the nurse identify as a sign of catheter occlusion?

• A. Bladder distention
• B. Frequent urination
• C. Dark urine
• D. Increased thirst

Correct answer: A

Rationale: Bladder distention is the correct sign of catheter occlusion. When a catheter is occluded, the urine cannot drain properly, leading to the buildup of urine in the bladder and subsequent distention. Frequent urination, dark urine, and increased thirst are not typical signs of catheter occlusion. Frequent urination can be a sign of conditions like urinary tract infection, dark urine may indicate dehydration or other issues, and increased thirst can be related to various factors like diabetes or medication side effects.

3. A nurse is reviewing the medication class, benzodiazepines. The nurse would use caution when administering benzodiazepines to which of the clients below?

• A. A client with glaucoma
• B. A client with renal failure
• C. A client with hypertension
• D. A client with insomnia

Correct answer: A

Rationale: Benzodiazepines can increase intraocular pressure, which is why they must be used cautiously in patients with glaucoma. In clients with this condition, benzodiazepines can potentially worsen symptoms and lead to further complications involving the eyes. Therefore, administering benzodiazepines to a client with glaucoma should be done with caution. Choices B, C, and D are not directly contraindicated with benzodiazepines, making them less likely to cause harm compared to administering to a client with glaucoma.

4. A nurse is in the emergency department monitoring the hydration status of a client receiving oral rehydration. What should the nurse intervene for?

• A. Heart rate 120/min
• B. Urine output 30 mL/hour
• C. Blood pressure 110/70 mmHg
• D. Skin turgor is normal

Correct answer: A

Rationale: A heart rate of 120/min may indicate dehydration or inadequate hydration, prompting the need for IV fluid replacement. Elevated heart rate is a sensitive indicator of dehydration as the body attempts to maintain cardiac output. Urine output of 30 mL/hour is within the normal range (30 mL/hour is the minimum acceptable urine output for an adult). Blood pressure of 110/70 mmHg is within the normal range. Normal skin turgor is a positive sign indicating adequate hydration.

5. A nurse is caring for a client who has chronic kidney disease. Which of the following diets should the nurse anticipate the provider to prescribe?

• A. 4 g sodium diet
• B. Potassium-restricted diet
• C. High phosphorus diet
• D. High protein diet

Correct answer: B

Rationale: Clients with chronic kidney disease often have difficulty regulating potassium levels in their blood. A potassium-restricted diet helps prevent hyperkalemia, a common complication in these clients. High sodium diet (Choice A) is typically avoided in kidney disease to prevent fluid retention and high blood pressure. High phosphorus diet (Choice C) is usually restricted in kidney disease as elevated phosphorus levels can lead to bone and heart problems. While protein is important for overall health, a high protein diet (Choice D) can put extra strain on the kidneys and is usually limited in chronic kidney disease.

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