Nursing Elites

1. 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.

2. A nurse is providing teaching about the Mediterranean diet to a client who has a new diagnosis of hypertension. Which of the following statements by the client indicates a need for further teaching?

• A. I will limit my intake of red meat to twice monthly.
• B. I can have dairy in moderate portions daily.
• C. I can have fish two times a week.
• D. I can drink wine in moderation.

Correct answer: A

Rationale: The correct answer is A. In the Mediterranean diet, red meat should be limited to two times monthly, not weekly. Choice B is correct as dairy in moderate portions daily is suitable for the Mediterranean diet. Choice C is also correct as having fish two times a week aligns with the Mediterranean diet. Choice D is correct as moderate wine consumption is a component of the Mediterranean diet.

3. A child is prescribed ferrous sulfate. Which of the following instructions should the nurse include?

• A. Take with meals
• B. Take at bedtime
• C. Take with a glass of milk
• D. Take with a glass of orange juice

Correct answer: D

Rationale: The correct answer is to take ferrous sulfate with a glass of orange juice. Vitamin C, found in orange juice, enhances iron absorption. Taking iron with milk (choice C) is not recommended as it reduces iron absorption. Taking it with meals (choice A) can hinder its absorption due to other food components. Taking it at bedtime (choice B) doesn't affect absorption but might cause gastrointestinal upset in some individuals.

4. A nurse is providing discharge teaching for a client newly prescribed methadone. Which statement indicates a need for further teaching?

• A. I understand methadone slows my breathing.
• B. I understand methadone may cause me to have trouble sleeping.
• C. I will avoid alcohol while taking this medication.
• D. I’ll change positions slowly to prevent dizziness.

Correct answer: B

Rationale: The correct answer is B. Trouble sleeping is not a typical side effect of methadone; the nurse should clarify this misunderstanding. Choices A, C, and D are all correct statements regarding methadone. Methadone can indeed slow breathing, so it is important for the client to be aware of this effect. Avoiding alcohol while taking methadone is crucial due to the increased risk of central nervous system depression when alcohol is combined with methadone. Additionally, changing positions slowly can help prevent dizziness, which can be a side effect of methadone.

5. A nurse is planning care for a client who has Alzheimer's disease and demonstrates confusion and wandering behavior. Which of the following should the nurse include in the plan of care?

• A. Place the client in seclusion when she is confused
• B. Request a prescription for PRN restraints when the client is wandering
• C. Dim the lighting in the client’s room
• D. Leave one side rail up on the client's bed

Correct answer: D

Rationale: The correct answer is to leave one side rail up on the client's bed. This action can help prevent falls while allowing the client to get up safely when needed, reducing the risk of injury from wandering. Placing the client in seclusion (Choice A) is not appropriate as it can lead to increased agitation and distress. Requesting restraints (Choice B) should be avoided as it can increase the risk of injuries and is not recommended for clients with Alzheimer's. Dimming the lighting (Choice C) may increase confusion and disorientation in clients with Alzheimer's disease.

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