Nursing Elites

1. A nurse is caring for a client who has heart failure and is receiving furosemide. Which of the following findings should the nurse identify as a therapeutic effect of the medication?

• A. Increased shortness of breath.
• B. Weight gain of 2.3 kg (5 lb).
• C. Clear lung sounds.
• D. Bounding pulse.

Correct answer: C

Rationale: The correct answer is C: Clear lung sounds. Clear lung sounds indicate a therapeutic effect of furosemide, as the medication helps reduce fluid overload in heart failure. Choice A, increased shortness of breath, is incorrect as furosemide is used to relieve symptoms like shortness of breath. Choice B, weight gain of 2.3 kg (5 lb), is incorrect as furosemide is a diuretic that helps reduce fluid retention leading to weight loss. Choice D, bounding pulse, is incorrect as furosemide does not directly impact the pulse rate.

2. A nurse is providing teaching to a client who is experiencing preterm contractions and dehydration. Which of the following statements should the nurse make?

• A. Dehydration is treated with calcium supplements
• B. Dehydration can increase the risk of preterm labor
• C. Dehydration can increase gastroesophageal reflux
• D. Dehydration is caused by a decreased hemoglobin and hematocrit

Correct answer: B

Rationale: The correct statement the nurse should make is that dehydration can increase the risk of preterm labor. Dehydration reduces amniotic fluid and uterine blood flow, potentially leading to preterm contractions. Choice A is incorrect because dehydration is not treated with calcium supplements but rather with adequate fluid intake. Choice C is incorrect as dehydration does not directly increase gastroesophageal reflux. Choice D is incorrect as dehydration is not caused by decreased hemoglobin and hematocrit levels but rather by insufficient fluid intake or excessive fluid loss.

3. A nurse is caring for a client who has an indwelling urinary catheter. Which of the following interventions should the nurse implement to prevent catheter-associated infections?

• A. Change the catheter every 24 hours
• B. Ensure the drainage bag is positioned above the bladder
• C. Perform routine irrigation of the catheter
• D. Empty the drainage bag every 4 hours

Correct answer: B

Rationale: The correct answer is to ensure the drainage bag is positioned above the bladder. This positioning prevents urine reflux into the bladder, reducing the risk of catheter-associated infections. Changing the catheter too frequently (Choice A) can actually increase the risk of infection by introducing pathogens. Performing routine catheter irrigation (Choice C) is no longer recommended as it can increase the risk of infection by introducing bacteria. Emptying the drainage bag every 4 hours (Choice D) is a standard practice to prevent urinary stasis but is not directly related to preventing catheter-associated infections.

4. What is the priority nursing intervention for a patient experiencing an acute asthma attack?

• A. Administer bronchodilators
• B. Administer corticosteroids
• C. Provide supplemental oxygen
• D. Start IV fluids

Correct answer: A

Rationale: The correct answer is to administer bronchodilators as the priority nursing intervention for a patient with an acute asthma attack. Bronchodilators help open the airways and improve airflow, which is crucial in managing acute asthma symptoms. Administering corticosteroids (Choice B) is also important in the treatment plan, but it is not the priority intervention during an acute attack. Providing supplemental oxygen (Choice C) may be necessary but is not the priority initial intervention. Starting IV fluids (Choice D) is not typically indicated as a priority intervention for an acute asthma attack.

5. A client who has a new prescription for lithium is receiving teaching from a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. ''I will avoid eating foods that contain tyramine.''
• B. ''I should increase my salt intake while taking this medication.''
• C. ''I should drink at least 2 liters of water each day while taking this medication.''
• D. ''I should avoid consuming caffeinated beverages while taking this medication.''

Correct answer: C

Rationale: The correct answer is C. Drinking at least 2 liters of water daily is crucial for clients taking lithium to prevent dehydration and lithium toxicity. Lithium is a salt, so it's important for clients to maintain adequate hydration. Option A is incorrect because lithium does not interact with tyramine-containing foods. Option B is incorrect because increasing salt intake is not necessary and can actually exacerbate lithium toxicity. Option D is incorrect because avoiding caffeinated beverages is not a priority teaching point for clients taking lithium.

Similar Questions