Nursing Elites

1. A client with heart failure is receiving discharge teaching. Which statement by the client indicates an understanding of the teaching?

• A. I will weigh myself once a week.
• B. I will take my diuretic medication in the evening.
• C. I will limit my fluid intake to 3 liters per day.
• D. I will call my doctor if I notice swelling in my feet.

Correct answer: D

Rationale: The correct answer is D. Swelling in the feet can indicate worsening heart failure due to fluid retention, and clients should report this to their healthcare provider immediately. Choices A, B, and C are incorrect because weighing once a week may not provide timely information on fluid retention, timing of diuretic medication is usually advised in the morning to prevent nocturia, and limiting fluid intake to 3 liters per day may not be appropriate for all clients with heart failure.

2. When admitting a client with fever, confusion, and decreased level of consciousness, what should the nurse do first after obtaining the client's history and assessment?

• A. Identify the client's needs
• B. Start intravenous fluids
• C. Notify the provider
• D. Conduct a neurological assessment

Correct answer: A

Rationale: When a client presents with fever, confusion, and decreased level of consciousness, the first step should be to identify the client's needs. This involves recognizing any immediate concerns or issues that require urgent attention. Starting intravenous fluids, notifying the provider, or conducting a neurological assessment may be necessary actions but should come after identifying the client's needs to ensure proper prioritization of care.

3. A nurse is teaching a newly licensed nurse about contraindications to ceftriaxone. The nurse should include a severe allergy to which of the following medications as a contraindication to ceftriaxone?

• A. Gentamicin
• B. Clindamycin
• C. Piperacillin
• D. Sulfamethoxazole-trimethoprim

Correct answer: C

Rationale: Ceftriaxone is a cephalosporin, and individuals with a penicillin allergy (such as Piperacillin) may have cross-sensitivity, making it contraindicated. Gentamicin (Choice A) belongs to the aminoglycoside class, not related to cephalosporins. Clindamycin (Choice B) is a lincosamide antibiotic and is not typically associated with cross-allergies to cephalosporins. Sulfamethoxazole-trimethoprim (Choice D) is a sulfonamide antibiotic, also not directly related to ceftriaxone.

4. When reinforcing teaching about self-care with a patient who has pelvic inflammatory disease and does not speak English, what action by the nurse is appropriate?

• A. Provide written instructions in English.
• B. Use family members as translators.
• C. Seek assistance from a facility-approved interpreter.
• D. Use online translation tools.

Correct answer: C

Rationale: When communicating with a patient who does not speak English, it is crucial to seek assistance from a facility-approved interpreter. Using family members as translators can lead to inaccuracies, breaches in confidentiality, and discomfort for the patient. Online translation tools may not provide accurate or context-specific translations, which can result in misunderstandings. Providing written instructions in English would not be effective if the patient does not understand the language.

5. When a nurse is interviewing a client who is requesting oral contraceptives, which finding in the client’s history is a contraindication to combined oral contraceptives?

• A. Thyroid disease
• B. Allergy to penicillin
• C. Impaired liver function
• D. Abnormal blood glucose levels

Correct answer: C

Rationale: The correct answer is C: Impaired liver function. Impaired liver function is a contraindication to the use of oral contraceptives because they are metabolized in the liver. Choices A, B, and D are incorrect. Thyroid disease, allergy to penicillin, and abnormal blood glucose levels are not contraindications to combined oral contraceptives.

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