Nursing Elites

1. A client who has a new prescription for lithium is receiving discharge teaching from a nurse. Which of the following client statements indicates an understanding of the teaching?

• A. I will need to have my blood levels checked regularly while taking this medication.
• B. I should take this medication on an empty stomach.
• C. I should avoid eating foods that are high in sodium.
• D. I should stop taking this medication if I experience nausea.

Correct answer: A

Rationale: The correct answer is A. Clients prescribed lithium need regular monitoring of blood levels to ensure the medication's effectiveness and safety. This monitoring helps to keep the medication within the therapeutic range and prevent toxicity. Choice B is incorrect because lithium is usually taken with food to minimize gastrointestinal side effects. Choice C is not directly related to lithium therapy; however, excessive sodium intake can affect lithium levels. Choice D is incorrect as abruptly stopping lithium can lead to adverse effects and should only be done under healthcare provider guidance.

2. A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse take?

• A. Position the client on their left side.
• B. Insert the enema tubing 8 cm (3.1 in) into the client's rectum.
• C. Hold the container of the enema solution 61 cm (24 in) above the client.
• D. Advance the enema tubing 15 cm (6 in) into the client's rectum.

Correct answer: C

Rationale: The correct action the nurse should take when administering a cleansing enema is to hold the container of the enema solution 61 cm (24 in) above the client. This height facilitates the proper flow of the solution into the client's rectum. Positioning the client on their left side helps facilitate the administration process, but it is not the specific action related to the enema solution. Inserting the enema tubing 8 cm (3.1 in) into the rectum is incorrect as it may not deliver the solution effectively. Advancing the enema tubing 15 cm (6 in) into the client's rectum is excessive and could cause trauma.

3. What is the appropriate intervention when a patient experiences a fall?

• A. Assess for injuries
• B. Call for help
• C. Document the fall
• D. Notify the healthcare provider

Correct answer: A

Rationale: The appropriate intervention when a patient experiences a fall is to assess for injuries. This immediate action helps in identifying any harm or complications resulting from the fall, allowing for timely intervention. Calling for help may be necessary after assessing the injuries, but the priority is to evaluate the patient's condition. Documenting the fall is important for record-keeping purposes but should come after ensuring the patient's safety. Notifying the healthcare provider can be done once the assessment has been completed and any necessary initial interventions have been initiated.

4. How should a healthcare professional assess for fluid overload in a patient with heart failure?

• A. Monitor daily weight
• B. Check for edema
• C. Monitor blood pressure
• D. Check oxygen saturation

Correct answer: A

Rationale: Monitoring daily weight is the most accurate way to assess fluid overload in patients with heart failure. In heart failure, the body retains excess fluid, leading to weight gain. Monitoring daily weight allows healthcare professionals to track fluid retention accurately. Checking for edema (Choice B) is a valuable assessment technique, but it may not be as sensitive as monitoring daily weight. Monitoring blood pressure (Choice C) is essential in managing heart failure, but it is not the most accurate way to assess fluid overload. Checking oxygen saturation (Choice D) is important to assess respiratory status but is not directly related to fluid overload in heart failure.

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

• A. Take this medication with food.
• B. You may experience a persistent dry cough.
• C. Increase your intake of foods high in potassium.
• D. You should avoid eating grapefruit while taking this medication.

Correct answer: B

Rationale: The correct answer is B. A persistent dry cough is a common side effect of captopril, an ACE inhibitor, and should be included in the teaching. Choice A is incorrect because captopril is usually taken on an empty stomach. Choice C is incorrect because captopril can increase potassium levels, so there is no need to further increase potassium intake. Choice D is incorrect because captopril does not interact with grapefruit.

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