Nursing Elites

1. A nurse is planning care for a client who is postoperative following a laminectomy. Which of the following interventions should the nurse include in the plan of care?

• A. Elevate the client's legs while in bed.
• B. Reposition the client every 2 hours.
• C. Maintain bed rest for the first 24 hours postoperatively.
• D. Ambulate the client on the first postoperative day.

Correct answer: D

Rationale: Ambulating the client on the first postoperative day is crucial to prevent complications like deep vein thrombosis and aid in the recovery process. Elevating the legs while in bed can help with circulation but is not as effective in preventing complications related to immobility post-surgery. Repositioning every 2 hours is important for preventing pressure ulcers but does not directly address postoperative care. Maintaining bed rest for the first 24 hours postoperatively can increase the risk of complications associated with immobility, making early ambulation a more appropriate intervention.

2. A client is receiving discharge teaching regarding a new prescription for warfarin. Which of the following statements by the client indicates a need for further teaching?

• A. I will eat more leafy green vegetables while taking warfarin.
• B. I will have my INR checked regularly while taking warfarin.
• C. I will avoid drinking grapefruit juice while taking warfarin.
• D. I will use a soft toothbrush while taking warfarin.

Correct answer: A

Rationale: The correct answer is A. Clients taking warfarin should avoid leafy green vegetables as they are high in vitamin K, which can reduce the effectiveness of the medication. Therefore, the statement 'I will eat more leafy green vegetables while taking warfarin' indicates a need for further teaching. Choice B is correct as regular monitoring of INR levels is necessary for clients on warfarin. Choice C is correct as grapefruit juice can interact with warfarin and should be avoided. Choice D is correct as using a soft toothbrush is recommended to prevent gum bleeding while on warfarin.

3. A nurse is assessing a client who has a new diagnosis of diabetes mellitus. Which of the following findings should the nurse expect?

• A. Increased urinary output.
• B. Weight gain.
• C. Blurred vision.
• D. Diaphoresis.

Correct answer: A

Rationale: Increased urinary output is a common finding in clients with diabetes mellitus due to hyperglycemia and osmotic diuresis. This results in the body trying to eliminate excess glucose through urine, leading to increased urinary frequency and volume. Weight gain is not typically associated with diabetes mellitus but may occur in poorly controlled cases due to increased calorie intake. Blurred vision is more commonly associated with acute complications like hyperglycemia or hypoglycemia. Diaphoresis, or excessive sweating, is not a typical finding in diabetes mellitus but can be seen in conditions like hypoglycemia.

4. A client is prescribed albuterol. Which of the following instructions should the nurse include?

• A. Take this medication before meals.
• B. You might experience tremors while taking this medication.
• C. Limit your caffeine intake while taking this medication.
• D. Take this medication at bedtime.

Correct answer: B

Rationale: The correct answer is B. Albuterol can cause tremors as a common side effect. Instructing the client about this potential side effect is crucial for their awareness and preparedness. Choices A, C, and D are incorrect because taking albuterol before meals, limiting caffeine intake, or taking it at bedtime are not specific instructions related to managing the side effects of albuterol like tremors.

5. A nurse is providing discharge teaching to a client who has a new prescription for lisinopril. Which of the following instructions should the nurse include?

• A. Take this medication in the morning.
• B. You may experience a persistent cough while taking this medication.
• C. Avoid taking this medication with a potassium supplement.
• D. Take this medication with a full glass of water.

Correct answer: B

Rationale: The correct answer is B: 'You may experience a persistent cough while taking this medication.' Lisinopril is known to cause a persistent cough as a common side effect. It is essential for the nurse to educate the client about this potential side effect, as it should be reported to the healthcare provider. Choice A is incorrect because lisinopril is usually taken once daily, but not necessarily at bedtime. Choice C is incorrect because lisinopril can actually increase potassium levels, so taking it with a potassium supplement may lead to hyperkalemia. Choice D is incorrect because antacids may reduce the effectiveness of lisinopril, so it should not be taken with them.

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