Nursing Elites

1. A client who has a new prescription for spironolactone is being taught by a nurse. Which of the following client statements indicates an understanding of the teaching?

• A. I will avoid foods that are high in potassium.
• B. I will avoid foods that are high in sodium.
• C. I will need to have my blood pressure checked regularly while taking this medication.
• D. I will need to have my potassium levels checked regularly while taking this medication.

Correct answer: D

Rationale: The correct answer is D because clients taking spironolactone should have their potassium levels checked regularly. Spironolactone is a potassium-sparing diuretic, meaning it helps the body retain potassium and can lead to hyperkalemia if levels become too high. Choices A, B, and C are incorrect because avoiding foods high in potassium, sodium, or monitoring blood pressure are not specific to the teaching related to spironolactone.

2. A client who is at 38 weeks gestation, is in active labor, and has ruptured membranes. Which of the following actions should the nurse take?

• A. Insert an indwelling urinary catheter
• B. Apply fetal heart rate monitor
• C. Initiate fundal massage
• D. Initiate an oxytocin IV infusion

Correct answer: B

Rationale: Applying a fetal heart rate monitor is the priority action in this scenario as it helps assess the well-being of the fetus during labor. This monitoring is crucial to detect any signs of fetal distress and guide interventions. Inserting an indwelling urinary catheter (Choice A) is not a priority at this time unless there are specific indications. Initiating fundal massage (Choice C) is not necessary in this situation as the focus should be on fetal assessment. Initiating an oxytocin IV infusion (Choice D) is not indicated until the stage of labor and the progress of labor are determined.

3. A client in end-stage osteoporosis is reporting severe pain, with a respiratory rate of 14 per minute. Which of the following medications should the nurse expect to be the highest priority to administer to the client?

• A. Promethazine
• B. Hydromorphone
• C. Ketorolac
• D. Amitriptyline

Correct answer: B

Rationale: In a client with severe pain like the one described, the priority medication to administer is a potent analgesic like hydromorphone. Hydromorphone is a strong opioid pain medication that can effectively manage severe pain. Promethazine (Choice A) is an antiemetic and antihistamine, not a pain medication. Ketorolac (Choice C) is a nonsteroidal anti-inflammatory drug (NSAID) that is contraindicated in end-stage renal disease due to its potential to cause kidney damage. Amitriptyline (Choice D) is a tricyclic antidepressant used for conditions like depression and neuropathic pain, but it is not the first-line treatment for severe acute pain.

4. What is the most important assessment for a patient with respiratory distress?

• A. Monitor oxygen saturation
• B. Check for abnormal breath sounds
• C. Check for pitting edema
• D. Perform a neurological exam

Correct answer: A

Rationale: Monitoring oxygen saturation is crucial in assessing a patient with respiratory distress because it helps determine if the patient is receiving adequate oxygen. Oxygen saturation levels provide immediate feedback on the efficiency of oxygen delivery to the tissues. Checking for abnormal breath sounds (Choice B) is relevant in respiratory assessments, but it is secondary to assessing oxygen saturation. Pitting edema (Choice C) and performing a neurological exam (Choice D) are not directly related to assessing respiratory distress and are not the primary focus when managing a patient with breathing difficulties.

5. 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.

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