Nursing Elites

1. A client with schizophrenia starting therapy with clozapine is being discharged. Which symptom should the client report to the provider as the highest priority?

• A. Constipation
• B. Blurred vision
• C. Fever
• D. Dry mouth

Correct answer: C

Rationale: The correct answer is C: Fever. When a client is taking clozapine, fever can indicate serious conditions such as infection or severe reactions, which need immediate medical attention. Constipation (choice A), blurred vision (choice B), and dry mouth (choice D) are common side effects of clozapine but are not as urgent as fever. Constipation can be managed with dietary changes or medications, blurred vision can improve over time, and dry mouth can be relieved with frequent sips of water.

2. A nurse is planning care for a client who is 1 day postoperative following a total knee arthroplasty. Which of the following interventions should the nurse include?

• A. Keep the affected leg elevated as needed.
• B. Apply ice packs to the affected knee as prescribed.
• C. Encourage the client to ambulate as soon as possible.
• D. Perform range-of-motion exercises as instructed.

Correct answer: C

Rationale: Encouraging the client to ambulate as soon as possible is essential in preventing complications like deep vein thrombosis post knee arthroplasty. While keeping the affected leg elevated and applying ice packs can be beneficial in certain situations, early ambulation takes precedence in this case. Performing range-of-motion exercises hourly may not be necessary and could potentially cause more harm than good if not done correctly or excessively.

3. A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following actions should the nurse take?

• A. Administer haloperidol as prescribed.
• B. Keep the client in a supine position.
• C. Administer lorazepam as prescribed.
• D. Encourage the client to drink fluids with meals.

Correct answer: C

Rationale: The correct action the nurse should take when caring for a client experiencing acute alcohol withdrawal is to administer lorazepam as prescribed. Lorazepam is a benzodiazepine used to prevent seizures and manage agitation in clients undergoing alcohol withdrawal. Administering haloperidol (Choice A) is not recommended in alcohol withdrawal as it may lower the seizure threshold. Keeping the client in a supine position (Choice B) is not specifically indicated in managing alcohol withdrawal. Encouraging the client to drink fluids with meals (Choice D) is important for hydration but does not address the acute symptoms of alcohol withdrawal.

4. A nurse is caring for a client who has a prescription for furosemide. The nurse should monitor the client for which of the following electrolyte imbalances?

• A. Hypernatremia
• B. Hypokalemia
• C. Hypercalcemia
• D. Hypomagnesemia

Correct answer: B

Rationale: The correct answer is B: Hypokalemia. Furosemide, a loop diuretic, can cause potassium loss leading to hypokalemia. Monitoring potassium levels is crucial as low potassium can result in various complications like cardiac dysrhythmias. Choices A, C, and D are incorrect. Hypernatremia is high sodium levels, which are not typically associated with furosemide use. Hypercalcemia is elevated calcium levels and hypomagnesemia is low magnesium levels, which are not the primary electrolyte imbalances associated with furosemide.

5. A nurse is caring for a client who is postoperative following a cholecystectomy. Which of the following findings should the nurse report to the provider?

• A. Blood pressure of 110/70 mm Hg
• B. Temperature of 37.2°C (99°F)
• C. Serosanguineous wound drainage
• D. Bile-colored drainage from the surgical site

Correct answer: D

Rationale: Bile-colored drainage from the surgical site can indicate a bile leak, which is an abnormal finding and should be reported. A blood pressure of 110/70 mm Hg and a temperature of 37.2°C (99°F) are within normal ranges for a postoperative client. Serosanguineous wound drainage, which is a mix of blood and serum, is expected following a surgery like cholecystectomy. Therefore, choices A, B, and C are not findings that require immediate reporting.

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