Nursing Elites

1. A nurse is caring for a client who has undergone a bronchoscopy. Which assessment finding requires immediate intervention?

• A. Oxygen saturation of 95%
• B. Blood pressure of 130/85 mm Hg
• C. Coughing up small amounts of sputum
• D. Absent gag reflex

Correct answer: D

Rationale: An absent gag reflex is a critical finding that requires immediate intervention to prevent aspiration. This can lead to the aspiration of oral or gastric contents into the lungs, potentially causing serious respiratory complications. Oxygen saturation of 95% is within the normal range, a blood pressure of 130/85 mm Hg is also within normal limits, and coughing up small amounts of sputum is an expected finding after a bronchoscopy procedure.

2. A client is being taught about a new prescription for furosemide. Which of the following statements by the client indicates an understanding of the teaching?

• A. This medication will decrease my potassium levels.
• B. I should eat a banana every day to increase my potassium intake.
• C. I will stop taking this medication if I experience a cough.
• D. I should avoid drinking alcohol while taking this medication.

Correct answer: D

Rationale: The correct answer is D. Clients taking furosemide should avoid alcohol because it can lead to dehydration and potential interactions with the medication. Choices A and B are incorrect because furosemide is a diuretic that can actually lower potassium levels, so the client should not expect an increase in potassium levels or solely rely on bananas for potassium intake. Choice C is incorrect because a cough is not a common side effect of furosemide and should not be a reason to stop taking the medication.

3. A nurse is caring for a client who has a new prescription for metformin. Which of the following instructions should the nurse include?

• A. Take this medication on an empty stomach.
• B. You should avoid eating foods high in potassium.
• C. You should take this medication with meals to improve absorption.
• D. Take this medication before bed to prevent drowsiness.

Correct answer: C

Rationale: The correct instruction for a client prescribed metformin is to take the medication with meals to improve absorption and reduce gastrointestinal upset. Metformin is typically recommended to be taken with food to minimize side effects. Option A is incorrect as taking metformin on an empty stomach may increase the risk of gastrointestinal side effects. Option B is unrelated as metformin does not interact with potassium-rich foods. Option D is also incorrect as metformin does not cause drowsiness, so there is no need to take it before bed.

4. A client has a new prescription for enoxaparin. Which of the following instructions should the nurse include?

• A. Take this medication with food to reduce stomach upset.
• B. Inject this medication into the muscle.
• C. Massage the injection site after administering the medication.
• D. Inject this medication into the abdomen.

Correct answer: D

Rationale: The correct answer is D because enoxaparin should be injected into the abdomen to ensure proper absorption. Choice A is incorrect as enoxaparin should not be taken with food. Choice B is incorrect as enoxaparin should be injected subcutaneously, not into the muscle. Choice C is incorrect as massaging the injection site after administering enoxaparin is not recommended.

5. How should a healthcare professional assess a patient for dehydration?

• A. Check for skin turgor
• B. Monitor blood pressure
• C. Check for dry mucous membranes
• D. Monitor urine output

Correct answer: A

Rationale: Checking for skin turgor is a reliable method to assess dehydration in patients. Skin turgor refers to the skin's elasticity and hydration status. When a healthcare professional gently pinches the skin on the back of the patient's hand or forearm, dehydration is indicated by the skin not snapping back immediately. Monitoring blood pressure (choice B) is important but is more indicative of cardiovascular status rather than dehydration specifically. Checking for dry mucous membranes (choice C) can be a sign of dehydration, but skin turgor is a more direct assessment. Monitoring urine output (choice D) is also essential but may not provide immediate feedback on hydration status as skin turgor does.

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