Nursing Elites

1. A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which action should the nurse take?

• A. Offer fluids every 2 hours.
• B. Document the client's behavior prior to being placed in seclusion.
• C. Discuss with the client their inappropriate behavior prior to seclusion.
• D. Assess the client's behavior every hour.

Correct answer: B

Rationale: The correct answer is to document the client's behavior prior to seclusion. Documenting the behavior is crucial as it helps justify the need for seclusion, provides a clear record of events leading up to the intervention, and ensures transparency in the client's care. Offering fluids every 2 hours (Choice A) is important for hydration but is not directly related to the situation of seclusion. Discussing the inappropriate behavior with the client (Choice C) may not be safe or appropriate when seclusion is necessary for preventing harm. Assessing the client's behavior every hour (Choice D) is important but may not be the most immediate action needed when seclusion is already in place.

2. A nurse is assessing a client who has acute pancreatitis. Which of the following findings should the nurse expect?

• A. Left upper quadrant pain.
• B. Periumbilical pain.
• C. Rebound tenderness.
• D. Flank pain.

Correct answer: A

Rationale: Corrected Rationale: The correct answer is A, left upper quadrant pain. In acute pancreatitis, inflammation of the pancreas commonly causes pain in the left upper quadrant of the abdomen. This pain can be severe and radiate to the back. Periumbilical pain (choice B) is more indicative of acute appendicitis. Rebound tenderness (choice C) is associated with peritoneal inflammation, not specifically pancreatitis. Flank pain (choice D) is more characteristic of conditions involving the kidneys or ureters, such as renal colic.

3. A nurse is caring for a client who has a prescription for a clear liquid diet. Which of the following items should the nurse offer to the client?

• A. Tomato soup
• B. Apple juice
• C. Chicken broth
• D. Cranberry juice

Correct answer: C

Rationale: The correct answer is C, Chicken broth. A clear liquid diet includes clear fluids and foods that are liquid at room temperature. Chicken broth is allowed on a clear liquid diet as it is a clear liquid, while tomato soup, apple juice, and cranberry juice are not clear liquids. Tomato soup is a thicker substance and not allowed on a clear liquid diet. Apple juice and cranberry juice are also not clear liquids because they contain pulp and are not transparent like broth.

4. Which electrolyte imbalance is most concerning for a patient on furosemide?

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

Correct answer: A

Rationale: The correct answer is hypokalemia. Furosemide, a loop diuretic, can lead to potassium loss through increased urinary excretion, making hypokalemia the most concerning electrolyte imbalance. Hyponatremia (Choice B) is not typically associated with furosemide use. Hyperkalemia (Choice C) is less likely due to furosemide's potassium-wasting effect. Hypercalcemia (Choice D) is not a common electrolyte imbalance seen with furosemide.

5. 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.

Similar Questions