Nursing Elites

1. A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will limit my intake of protein to prevent kidney damage.
• B. I will avoid taking ibuprofen for my headaches.
• C. I will monitor my blood glucose level before meals and at bedtime.
• D. I will reduce my intake of carbohydrates to manage my blood sugar.

Correct answer: C

Rationale: The correct answer is C. Monitoring blood glucose levels before meals and at bedtime is crucial for managing type 2 diabetes mellitus. Option A is incorrect because limiting protein intake is not a primary focus for diabetes management. Option B is unrelated to diabetes management and focuses on pain relief. Option D mentions reducing carbohydrate intake, which is a common dietary recommendation for managing blood sugar levels, but it is not as specific as monitoring blood glucose levels at key times.

2. A client is postoperative following cataract surgery. Which of the following instructions should the nurse include?

• A. Avoid lying flat for 24 hours after surgery.
• B. Avoid bending at the waist.
• C. Wear an eye patch at night for 1 week.
• D. Sleep on your affected side to reduce discomfort.

Correct answer: B

Rationale: The correct instruction that the nurse should include for a client postoperative following cataract surgery is to avoid bending at the waist. Bending at the waist can increase intraocular pressure, which is not recommended after cataract surgery. Choices A, C, and D are incorrect because lying flat for 24 hours after surgery may not be necessary, wearing an eye patch at night for a week is not a standard postoperative instruction for cataract surgery, and sleeping on the affected side may not necessarily reduce discomfort and can increase pressure on the eye.

3. A nurse is caring for a client who has a chest tube. Which of the following actions should the nurse take?

• A. Clamp the chest tube for 15 minutes every 2 hours.
• B. Empty the drainage collection chamber when it is half full.
• C. Keep the drainage system below the level of the client's chest.
• D. Strip the chest tube every 2 hours to maintain patency.

Correct answer: C

Rationale: The correct action the nurse should take when caring for a client with a chest tube is to keep the drainage system below the level of the client's chest. This positioning helps prevent fluid from flowing back into the pleural space, ensuring proper drainage and effective functioning of the chest tube. Clamping the chest tube intermittently or stripping it frequently can lead to complications and should be avoided. Emptying the drainage collection chamber at specific intervals may vary based on institutional protocols, but it should be done when it is no more than two-thirds full to prevent backflow and maintain accurate monitoring of drainage output.

4. What should the healthcare provider monitor for a patient receiving furosemide?

• A. Monitor urine output
• B. Monitor blood pressure
• C. Monitor potassium levels
• D. Monitor serum creatinine

Correct answer: C

Rationale: The correct answer is to monitor potassium levels when a patient is receiving furosemide because furosemide can cause potassium depletion. It is essential to monitor potassium levels to prevent complications such as hypokalemia. While monitoring urine output is important in assessing kidney function, and monitoring blood pressure and serum creatinine are relevant in certain situations, the priority when administering furosemide is to monitor potassium levels due to the medication's potential to deplete potassium.

5. A nurse is caring for a client who is receiving morphine for pain management. Which of the following findings indicates the client is experiencing an adverse effect of the medication?

• A. Diaphoresis
• B. Hypotension
• C. Urinary retention
• D. Tachycardia

Correct answer: C

Rationale: Urinary retention is an adverse effect of morphine, as it can lead to the relaxation of the detrusor muscle and sphincter constriction in the bladder. Diaphoresis, hypotension, and tachycardia are common side effects of morphine due to its vasodilatory effects and impact on the autonomic nervous system. Diaphoresis is excessive sweating, which can be a normal response to pain or fever. Hypotension and tachycardia can occur due to morphine's vasodilatory effects and its impact on the cardiovascular system. Therefore, the presence of urinary retention would indicate the need for further assessment and intervention.

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