Nursing Elites

1. A client with schizophrenia is experiencing auditory hallucinations. Which of the following actions should the nurse take first?

• A. Encourage the client to listen to music
• B. Ask the client what the voices are saying
• C. Provide the client with a distraction
• D. Administer an antipsychotic medication

Correct answer: B

Rationale: Asking the client what the voices are saying is the priority action as it helps assess the content of the hallucinations. This assessment is crucial to determine if the client is at risk of harm to themselves or others. Encouraging the client to listen to music or providing a distraction may not address the underlying issues related to the hallucinations. Administering antipsychotic medication, although important, should come after a thorough assessment of the hallucinations to ensure the right medication and dosage are provided.

2. A client is to undergo a liver biopsy. Which of the following instructions should the nurse provide to the client following the procedure?

• A. “Lie on your left side.”
• B. “Lie on your right side.”
• C. “Increase your fluid intake.”
• D. “Decrease your fluid intake.”

Correct answer: B

Rationale: Following a liver biopsy, the nurse should instruct the client to lie on the right side to promote hemostasis. This position helps apply pressure to the biopsy site, reducing the risk of bleeding. Instructing the client to lie on the left side (Choice A) would not provide the same benefit. Increasing fluid intake (Choice C) is generally beneficial post-procedure to prevent dehydration and promote healing. Decreasing fluid intake (Choice D) is not advisable as it can lead to dehydration and potential complications.

3. A nurse is caring for a client prescribed montelukast. Which of the following should the nurse include in teaching related to this medication?

• A. Advise the client to take the medication once daily at bedtime.
• B. This medication is for acute management of asthma.
• C. Avoid dairy products while taking this medication.
• D. If the client forgets to take the medication for a few days, he can double up on doses to catch up.

Correct answer: A

Rationale: The correct answer is to advise the client to take the medication once daily at bedtime. Montelukast, a leukotriene modifier, is used for long-term therapy of asthma in adults and children, as well as to prevent exercise-induced bronchospasm. It should be taken once daily in the evening for optimal effectiveness. Choice B is incorrect because montelukast is not for acute management but for long-term therapy. Choice C is incorrect as there is no need to avoid dairy products while taking montelukast. Choice D is incorrect and potentially harmful advice; clients should never double up on doses if they forget to take a medication.

4. A nurse is planning care for a client who has chronic renal failure. Which action should the nurse include in the plan of care?

• A. Encourage increased fluid intake
• B. Restrict protein intake to the RDA
• C. Increase dietary potassium
• D. Encourage foods high in sodium

Correct answer: B

Rationale: The correct action the nurse should include in the plan of care for a client with chronic renal failure is to restrict protein intake to the RDA. This is important because limiting protein helps reduce the buildup of waste products that the kidneys are unable to efficiently excrete. Encouraging increased fluid intake (choice A) may further burden the kidneys, increasing the risk of fluid overload. Increasing dietary potassium (choice C) is not recommended in chronic renal failure as impaired kidneys have difficulty regulating potassium levels. Encouraging foods high in sodium (choice D) is also not appropriate as excessive sodium intake can lead to fluid retention and hypertension, which are detrimental in renal failure.

5. A client is prescribed metronidazole for a bacterial infection. Which of the following should the nurse teach the client?

• A. Avoid alcohol while taking this medication
• B. It is safe to take during pregnancy
• C. Monitor for increased appetite
• D. It can cause hair loss

Correct answer: A

Rationale: The correct answer is A: 'Avoid alcohol while taking this medication.' Metronidazole can cause a disulfiram-like reaction with alcohol, leading to symptoms like nausea, vomiting, flushing, and headache. Therefore, clients should be instructed to avoid alcohol consumption. Choice B is incorrect because metronidazole is not considered safe during pregnancy, especially in the first trimester. Choice C is incorrect as metronidazole is not known to cause increased appetite. Choice D is also incorrect as hair loss is not a common side effect of metronidazole.

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