Nursing Elites

1. A client has been prescribed phenytoin. Which of the following should the nurse monitor to prevent toxicity?

• A. Blood pressure
• B. Complete blood count
• C. Serum phenytoin levels
• D. Liver function tests

Correct answer: C

Rationale: Corrected Rationale: Serum phenytoin levels should be regularly monitored to prevent toxicity because the therapeutic range is narrow. Monitoring blood pressure (choice A), complete blood count (choice B), and liver function tests (choice D) are not directly related to preventing phenytoin toxicity.

2. A healthcare professional is caring for a client receiving potassium-sparing diuretics. Which of the following should the healthcare professional monitor?

• A. Hypokalemia
• B. Hyperkalemia
• C. Hypoglycemia
• D. Hyponatremia

Correct answer: B

Rationale: Corrected Rationale: When a client is receiving potassium-sparing diuretics, the healthcare professional should monitor for hyperkalemia. Potassium-sparing diuretics can cause potassium retention, leading to elevated potassium levels in the blood. Monitoring potassium levels is crucial to prevent hyperkalemia-related complications such as cardiac arrhythmias. Choices A, C, and D are incorrect because potassium-sparing diuretics typically do not cause hypokalemia, hypoglycemia, or hyponatremia.

3. A client had a pituitary tumor removed. Which of the following findings requires further assessment?

• A. Glasgow scale score of 15
• B. Blood drainage on dressing measuring 3 cm
• C. Report of dry mouth
• D. Urinary output greater than fluid intake

Correct answer: D

Rationale: The correct answer is D. Increased urinary output greater than fluid intake can indicate diabetes insipidus, a common complication after pituitary surgery. Diabetes insipidus is characterized by the excretion of a large volume of dilute urine, leading to dehydration and electrolyte imbalances. This finding requires immediate assessment and intervention. Choice A, a Glasgow scale score of 15, indicates normal neurological functioning. Choice B, blood drainage on dressing measuring 3 cm, may require monitoring but is not a priority over the potential complication of diabetes insipidus. Choice C, a report of dry mouth, is a common complaint postoperatively and can be managed with oral care measures.

4. A nurse is reviewing information about advance directives with a newly admitted client. Which statement by the client indicates an understanding of the teaching?

• A. My family can make decisions if I am unable to.
• B. I have a living will that outlines my wishes when I am unable to make a decision.
• C. I can write down my wishes, but they aren't legally binding.
• D. I don't need to worry about this until I’m critically ill.

Correct answer: B

Rationale: Choice B is the correct answer because having a living will is a legal document that outlines a client's wishes when they are unable to make decisions, indicating a good understanding of advance directives. Choice A is incorrect because it doesn't mention a specific document like a living will. Choice C is incorrect because advance directives, like a living will, can be legally binding. Choice D is incorrect because planning for advance directives should ideally be done before a person becomes critically ill.

5. A client who signed an informed consent form for surgery but has since expressed doubts about the need for surgery should discuss concerns with the surgeon to obtain informed answers. Which statement should the nurse make?

• A. It's normal to feel unsure; the surgery will be beneficial
• B. You can cancel surgery any time without any consequences
• C. I'll inform the surgeon to answer your questions before surgery
• D. We can reschedule surgery for another day

Correct answer: C

Rationale: The correct answer is C because the nurse should facilitate communication between the client and the surgeon to address any doubts and provide necessary information. Choice A may invalidate the client's concerns and might not address the root of the issue. Choice B oversimplifies the situation and might not consider the potential consequences of canceling surgery. Choice D, while offering an alternative, does not address the client's doubts about the surgery.

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