Nursing Elites

1. While documenting client care, which of the following entries should the nurse identify as an example of implementing client care?

• A. Contacting the provider to report client findings
• B. Administering medications as prescribed
• C. Reviewing the client's lab results
• D. Discussing the care plan with the family

Correct answer: B

Rationale: Administering medications as prescribed is a clear example of implementing client care because it involves carrying out a specific aspect of the care plan. Contacting the provider to report client findings is more related to assessment and communication. Reviewing the client's lab results is part of assessment and data collection. Discussing the care plan with the family is focused on collaboration and planning, rather than direct implementation.

2. What is the first action when a client who is admitted with schizophrenia reports hearing voices telling them to harm themselves?

• A. Administer antipsychotic medication
• B. Ask the client what the voices are saying
• C. Distract the client with another activity
• D. Call the healthcare provider

Correct answer: B

Rationale: The correct first action when a client with schizophrenia reports hearing voices telling them to harm themselves is to ask the client what the voices are saying. This is important to assess the content of the hallucinations and determine if there is any immediate danger or suicidal intent. Administering antipsychotic medication without knowing the content of the voices or the level of danger could be inappropriate and potentially harmful. Distracting the client with another activity may not address the underlying issue of the hallucinations commanding harm. Calling the healthcare provider can be done after assessing the situation and gathering information from the client.

3. A healthcare professional is assessing a client with a history of heart disease. Which of the following findings should the healthcare professional monitor?

• A. Blood pressure
• B. Weight
• C. Heart rhythm
• D. All of the above

Correct answer: D

Rationale: Monitoring blood pressure, weight, and heart rhythm is crucial in clients with a history of heart disease as these parameters can indicate changes in the cardiovascular status. Changes in blood pressure can signify heart strain, weight fluctuations can be related to fluid retention or heart failure, and irregular heart rhythm can indicate arrhythmias or other cardiac issues. Monitoring all these parameters comprehensively allows for early detection of potential complications and timely intervention. Therefore, selecting 'All of the above' is the correct choice as it encompasses all the essential parameters for monitoring in clients with heart disease. Choices A, B, and C are incorrect as monitoring only one or two of these parameters may lead to missing important changes in the client's condition.

4. A healthcare provider is caring for a client with severe preeclampsia. Which of the following medications should the healthcare provider anticipate administering?

• A. Magnesium sulfate
• B. Oxytocin
• C. Misoprostol
• D. Nifedipine

Correct answer: A

Rationale: Magnesium sulfate is the correct answer as it is administered to prevent seizures in clients with severe preeclampsia. It acts as a central nervous system depressant and is the first-line treatment for eclampsia prevention. Oxytocin (Choice B) is used to induce or augment labor, not indicated specifically for preeclampsia. Misoprostol (Choice C) is used for labor induction and postpartum hemorrhage, not typically indicated for preeclampsia. Nifedipine (Choice D) is a calcium channel blocker used for managing hypertension in pregnancy but is not the first-line treatment for preventing seizures in severe preeclampsia.

5. A client has been prescribed metoclopramide. Which of the following should the nurse include in client education regarding this medication?

• A. Notify your provider if you experience restlessness or spasms of the face or neck.
• B. Take the medication only if you feel nauseous.
• C. Avoid drinking any fluids while taking this medication.
• D. Take the medication on an empty stomach.

Correct answer: A

Rationale: The correct answer is A: 'Notify your provider if you experience restlessness or spasms of the face or neck.' Metoclopramide can cause extrapyramidal symptoms, such as restlessness and muscle spasms, particularly of the face and neck. These symptoms should be reported to the provider immediately. Choice B is incorrect because metoclopramide is not meant to be taken only when feeling nauseous; it is used to treat nausea and vomiting. Choice C is incorrect because it is important to stay hydrated while taking metoclopramide. Choice D is incorrect because metoclopramide is usually taken before meals to improve gastric emptying, not necessarily on an empty stomach.

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