Nursing Elites

1. A nurse is caring for a client who is 4 hours postoperative following an open cholecystectomy. Which of the following actions should the nurse take?

• A. Monitor the client's urinary output.
• B. Assist the client to splint the incision with a pillow when coughing.
• C. Provide the client with a clear liquid diet.
• D. Encourage the client to ambulate in the hallway.

Correct answer: B

Rationale: Assisting the client to splint the incision with a pillow while coughing is the correct action in this scenario. This intervention helps reduce pain and prevent wound dehiscence, which is the partial or complete separation of the layers of a surgical wound. Monitoring urinary output is important but not the priority at this immediate postoperative stage. Providing a clear liquid diet may be indicated later but is not the most immediate concern. Encouraging ambulation is beneficial for preventing complications like deep vein thrombosis, but splinting the incision is more crucial at this early postoperative period.

2. A healthcare provider is providing discharge instructions to a client with type 2 diabetes mellitus. Which resource should the healthcare provider provide?

• A. Personal blogs about managing the adverse effects of diabetes medications.
• B. Food label recommendations from the Institute of Medicine.
• C. Diabetes medication information from the Physicians' Desk Reference.
• D. Food exchange lists for meal planning from the American Diabetes Association.

Correct answer: D

Rationale: Food exchange lists from the American Diabetes Association are a valuable resource for structured meal planning in individuals with diabetes. These lists categorize foods based on macronutrient content and help individuals plan balanced meals to manage blood sugar levels effectively. Personal blogs may not always provide accurate and evidence-based information. Food label recommendations from the Institute of Medicine are important but may not be as specific to meal planning for diabetes. Diabetes medication information is crucial but not the primary focus when providing dietary instructions.

3. A nurse is assessing a client who has heart failure and is receiving furosemide. Which of the following findings should the nurse identify as an indication that the client is developing hypokalemia?

• A. Positive Trousseau's sign.
• B. Hyperactive reflexes.
• C. Hypoactive bowel sounds.
• D. Decreased deep-tendon reflexes.

Correct answer: A

Rationale: The correct answer is A: Positive Trousseau's sign. When a patient receiving furosemide is developing hypokalemia, they may exhibit a positive Trousseau's sign, an indication of low potassium levels. This sign is elicited by inflating a blood pressure cuff above systolic pressure for a few minutes, resulting in carpal spasm. Choices B, C, and D are incorrect. Hyperactive reflexes are associated with hyperkalemia, not hypokalemia. Hypoactive bowel sounds are not specifically related to hypokalemia. Decreased deep-tendon reflexes are not typically seen in hypokalemia.

4. Which electrolyte imbalance should be closely monitored in patients on furosemide?

• A. Hypokalemia
• B. Hyponatremia
• C. Hyperkalemia
• D. Hypercalcemia

Correct answer: A

Rationale: The correct answer is A: Hypokalemia. Furosemide is a loop diuretic that can lead to potassium loss in the body, resulting in hypokalemia. Monitoring potassium levels is crucial in patients on furosemide to prevent complications such as cardiac arrhythmias and muscle weakness. Choice B, hyponatremia, is not typically associated with furosemide use. Hyperkalemia (choice C) and hypercalcemia (choice D) are not commonly linked to furosemide therapy; therefore, they are incorrect choices.

5. A nurse is assessing a client who has heart failure and is receiving digoxin. Which of the following findings should the nurse identify as an indication of digoxin toxicity?

• A. Bradycardia.
• B. Tachycardia.
• C. Nausea.
• D. Blurred vision.

Correct answer: D

Rationale: Corrected Rationale: Blurred vision is a classic sign of digoxin toxicity, indicating a potential overdose. It is crucial to recognize this symptom promptly and report it to the healthcare provider for immediate intervention. Bradycardia and nausea are common side effects of digoxin but not specific indicators of toxicity. Tachycardia is unlikely in digoxin toxicity since it usually causes a decrease in heart rate.

Similar Questions