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 reviewing the medical records of a group of older adult clients. The nurse should identify which of the following as a risk factor for developing infections?

• A. Increased physical activity
• B. Lowered immune system function
• C. Regular health screenings
• D. Proper nutrition

Correct answer: B

Rationale: The correct answer is B: Lowered immune system function. In older adults, a decline in immune system function increases the risk of developing infections. Increased physical activity (choice A) and proper nutrition (choice D) generally support immune function and overall health, reducing the risk of infections. Regular health screenings (choice C) are important for early detection of health issues but do not directly increase the risk of infections.

3. A nurse is planning to administer diltiazem via IV bolus to a client who has atrial fibrillation. Which of the following findings is a contraindication to the administration of diltiazem?

• A. Hypotension
• B. Tachycardia
• C. Decreased level of consciousness
• D. History of diuretic use

Correct answer: A

Rationale: The correct answer is A: Hypotension. Diltiazem, a calcium channel blocker, can cause hypotension. Administering diltiazem to a client with hypotension can further lower their blood pressure, leading to adverse effects like dizziness and syncope. Tachycardia (Choice B) is actually a common indication for diltiazem use, as it helps slow down the heart rate in conditions like atrial fibrillation. Decreased level of consciousness (Choice C) may require evaluation but is not a direct contraindication to diltiazem administration. History of diuretic use (Choice D) is not a contraindication to diltiazem, as the two medications can often be safely used together.

4. A nurse is preparing to administer IV furosemide. Which of the following should the nurse monitor for during the infusion?

• A. Increased urinary output
• B. Ototoxicity
• C. Hypokalemia
• D. Hypoglycemia

Correct answer: C

Rationale: The correct answer is C: Hypokalemia. Furosemide is a loop diuretic that works by increasing the excretion of water and electrolytes, particularly potassium. Therefore, the nurse should monitor for hypokalemia, as low potassium levels can lead to various complications such as cardiac dysrhythmias. Choice A, increased urinary output, is an expected effect of furosemide due to its diuretic action but is not a side effect needing monitoring. Ototoxicity (Choice B) is a potential adverse effect of other medications like aminoglycoside antibiotics, not furosemide. Hypoglycemia (Choice D) is not a common side effect associated with furosemide administration.

5. A client who is being admitted for induction of labor is receiving teaching about newborn safety from a nurse. Which of the following client statements indicates an understanding of the teaching?

• A. I will check the identification badge of anyone who removes my baby from our room.
• B. I should include a photo of my baby along with any public birth announcements on social media.
• C. I will allow my baby to sleep on the bed in my room when I am in the shower.
• D. I should expect the nurses to carry my baby in their arms to the nursery.

Correct answer: A

Rationale: Choice A is the correct answer because the client should verify the identification badge of anyone removing their baby to ensure the infant's safety and prevent abduction. This statement demonstrates an understanding of the importance of strict identification protocols in the hospital setting. Choice B is incorrect because including a photo of the baby in public announcements does not relate to newborn safety teaching. Choice C is incorrect as it is unsafe to allow a baby to sleep on the bed unsupervised. Choice D is incorrect because nurses typically encourage parents to carry their baby to the nursery themselves for bonding and security reasons.

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