Nursing Elites

1. A nurse is providing care for a client with thrombocytopenia. Which of the following actions should the nurse include?

• A. Encourage the client to floss daily.
• B. Remove fresh flowers from the client's room.
• C. Provide the client with a stool softener.
• D. Avoid serving raw vegetables.

Correct answer: C

Rationale: The correct action for a nurse caring for a client with thrombocytopenia is to provide the client with a stool softener. Thrombocytopenia is a condition characterized by low platelet count, which can lead to bleeding problems. Providing a stool softener helps prevent constipation, which in turn prevents straining during bowel movements, reducing the risk of bleeding. Encouraging the client to floss daily (Choice A) is not directly related to thrombocytopenia. Removing fresh flowers from the client's room (Choice B) is more related to infection control rather than managing thrombocytopenia. Avoiding serving raw vegetables (Choice D) is not directly linked to managing thrombocytopenia.

2. How should fluid balance be assessed in a patient with heart failure?

• A. Monitor daily weight
• B. Monitor input and output
• C. Check for edema
• D. Monitor blood pressure

Correct answer: A

Rationale: In patients with heart failure, monitoring daily weight is the most accurate method for assessing fluid balance. Weight gain can indicate fluid retention, a common issue in heart failure patients. Monitoring input and output (B) is essential but may not always accurately reflect fluid balance. Checking for edema (C) is important as it can indicate fluid accumulation, but daily weight monitoring is more precise. Monitoring blood pressure (D) is important in heart failure management but does not directly assess fluid balance.

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. A nurse is caring for a client who has heart failure and is receiving furosemide. Which of the following findings should the nurse identify as a therapeutic effect of the medication?

• A. Increased shortness of breath.
• B. Weight gain of 2.3 kg (5 lb).
• C. Clear lung sounds.
• D. Bounding pulse.

Correct answer: C

Rationale: The correct answer is C: Clear lung sounds. Clear lung sounds indicate a therapeutic effect of furosemide, as the medication helps reduce fluid overload in heart failure. Choice A, increased shortness of breath, is incorrect as furosemide is used to relieve symptoms like shortness of breath. Choice B, weight gain of 2.3 kg (5 lb), is incorrect as furosemide is a diuretic that helps reduce fluid retention leading to weight loss. Choice D, bounding pulse, is incorrect as furosemide does not directly impact the pulse rate.

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

• A. Take this medication in the evening before bed.
• B. Take this medication on an empty stomach.
• C. Take this medication with a full glass of milk.
• D. Take this medication with an antacid if you experience indigestion.

Correct answer: B

Rationale: The correct instruction when taking levothyroxine is to take it on an empty stomach. This enhances absorption and ensures the medication's effectiveness. Taking it with food or other substances, such as milk or antacids, can interfere with its absorption. Therefore, choices A, C, and D are incorrect.

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