Nursing Elites

1. A nurse is planning care for a client who is 1 day postoperative following a hypophysectomy for the removal of a pituitary tumor. Which of the following findings requires further assessment by the nurse?

• A. Glasgow Coma Scale score of 15
• B. Blood drainage on the initial dressing measuring 3 cm
• C. Report of dry mouth
• D. Urinary output greater than fluid intake

Correct answer: D

Rationale: The correct answer is D. Urinary output greater than fluid intake could indicate diabetes insipidus, a complication following hypophysectomy. Diabetes insipidus is characterized by excessive urination and extreme thirst due to inadequate levels of antidiuretic hormone (ADH). Options A, B, and C are all expected findings in the immediate postoperative period following a hypophysectomy. A Glasgow Coma Scale score of 15 indicates the highest level of consciousness, blood drainage on the initial dressing is a common finding after surgery, and dry mouth can be a side effect of anesthesia and surgical procedures.

2. How should a healthcare provider monitor a patient who has been prescribed digoxin?

• A. Monitor potassium levels
• B. Monitor heart rate
• C. Check digoxin levels
• D. Check blood glucose levels

Correct answer: C

Rationale: The correct way to monitor a patient who has been prescribed digoxin is by checking digoxin levels. Digoxin is a medication used to treat various heart conditions, and monitoring its levels in the blood is crucial to prevent toxicity. Monitoring potassium levels (Choice A) is important as well, as digoxin can affect potassium levels, but checking digoxin levels is more specific to monitoring the medication itself. Monitoring heart rate (Choice B) is relevant but does not directly assess the medication levels. Checking blood glucose levels (Choice D) is not typically indicated specifically for patients prescribed digoxin.

3. A nurse is admitting a client who is in labor and at 38 wks of gestation to the maternal newborn unit. The client has a history of herpes simplex virus 2. Which of the following questions is most appropriate for the nurse to ask the client?

• A. Have your membranes ruptured?
• B. How far apart are your contractions?
• C. Do you have any active lesions?
• D. Are you positive for beta strep?

Correct answer: C

Rationale: The most appropriate question for the nurse to ask the client in this situation is whether they have any active lesions due to the history of herpes simplex virus. This is crucial to assess the risk of transmission to the newborn during labor. Option A is not the priority in this case as the focus is on the client's history of herpes simplex virus. Option B is important but does not directly relate to the risk of herpes simplex virus transmission. Option D is unrelated to the client's condition and the current situation.

4. A client with a new diagnosis of type 2 diabetes mellitus is being taught about foot care by a nurse. Which of the following instructions should the nurse include?

• A. Soak your feet in warm water daily.
• B. Wear shoes that are one size larger than your normal size.
• C. Wear cotton socks to keep your feet dry.
• D. Trim your toenails straight across.

Correct answer: D

Rationale: The correct answer is D: "Trim your toenails straight across." This instruction is essential to prevent ingrown toenails in clients with diabetes. Soaking feet in warm water daily (choice A) may increase the risk of skin breakdown and infection. Wearing shoes one size larger than normal (choice B) can lead to friction and cause blisters. While wearing cotton socks (choice C) is generally recommended, the emphasis should be on moisture-wicking materials rather than just cotton.

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

• A. Take this medication with a meal.
• B. Increase your intake of potassium-rich foods.
• C. Avoid prolonged exposure to sunlight.
• D. Limit your intake of calcium-rich foods.

Correct answer: B

Rationale: The correct instruction for a client taking furosemide is to increase their intake of potassium-rich foods. Furosemide is a loop diuretic that can lead to potassium loss, so increasing potassium-rich foods helps prevent hypokalemia. Choice A is incorrect because furosemide is usually taken on an empty stomach. Choice C is unrelated to furosemide therapy. Choice D is incorrect as there is no need to limit calcium-rich foods while taking furosemide.

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