Nursing Elites

1. A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?

• A. A client who has sinus arrhythmia and is receiving cardiac monitoring.
• B. A client who has diabetes mellitus and a hemoglobin A1C of 6.8%.
• C. A client who has epidural analgesia and weakness in the lower extremities.
• D. A client who has a hip fracture and a new onset of tachypnea.

Correct answer: D

Rationale: The correct answer is D. New onset of tachypnea indicates a potential respiratory complication that requires immediate attention. Assessing the client with a hip fracture and tachypnea first is crucial to address the respiratory issue and prevent further deterioration. Choices A, B, and C do not present immediate life-threatening complications that require urgent assessment compared to a new onset of tachypnea.

2. What is the best strategy for managing fatigue in a client who has had an acute myocardial infarction and is concerned about self-care?

• A. Instruct the client to rest completely and avoid all self-care tasks
• B. Encourage the client to gradually resume self-care tasks with frequent rest periods
• C. Assign assistive personnel to complete all self-care tasks
• D. Ask the client's family to assist with self-care tasks

Correct answer: B

Rationale: The best strategy for managing fatigue in a client who has had an acute myocardial infarction and is concerned about self-care is to encourage the client to gradually resume self-care tasks with frequent rest periods. This approach helps the client regain independence while managing fatigue effectively. Choice A is incorrect because complete rest without any self-care tasks may hinder recovery and independence. Choice C is not the best option as it does not promote the client's independence. Choice D, while involving family support, does not empower the client to regain self-care abilities.

3. A client has a prescription for ciprofloxacin. Which of the following instructions should the nurse include?

• A. Take the medication with an antacid if you experience gastrointestinal upset.
• B. You should limit your caffeine intake while taking this medication.
• C. This medication may cause your urine to turn dark brown.
• D. You should avoid taking this medication with dairy products.

Correct answer: D

Rationale: The correct answer is D: 'You should avoid taking this medication with dairy products.' Ciprofloxacin should not be taken with dairy products as they can interfere with the absorption of the medication. Choice A is incorrect because ciprofloxacin should not be taken with antacids containing aluminum or magnesium. Choice B is incorrect as there is no specific limitation on caffeine intake associated with ciprofloxacin. Choice C is incorrect as ciprofloxacin does not typically cause urine to turn dark brown.

4. How should a healthcare provider assess a patient with potential diabetic ketoacidosis (DKA)?

• A. Monitor blood glucose and check for ketones in urine
• B. Administer insulin and provide fluids
• C. Administer potassium and check for electrolyte imbalance
• D. Administer sodium bicarbonate and monitor urine output

Correct answer: A

Rationale: Correct answer: To assess a patient with potential diabetic ketoacidosis (DKA), healthcare providers should monitor blood glucose and check for ketones in the urine. Elevated blood glucose levels and the presence of ketones in urine are indicative of DKA. Choice B is incorrect because administering insulin and providing fluids are treatments for DKA rather than assessment measures. Choice C is incorrect as administering potassium and checking for electrolyte imbalance are interventions related to managing DKA complications, not initial assessment. Choice D is incorrect because administering sodium bicarbonate and monitoring urine output are not primary assessment actions for DKA.

5. A client is undergoing radiation therapy. Which of the following actions should the nurse take to prevent skin irritation?

• A. Apply heat packs to the area
• B. Use perfumed soap to cleanse the area
• C. Keep the area moist with lotion
• D. Avoid sun exposure to the treated area

Correct answer: D

Rationale: Avoiding sun exposure is crucial to prevent skin irritation and burns in clients undergoing radiation therapy. Radiation therapy makes the skin more sensitive to sunlight, increasing the risk of skin damage. Applying heat packs (choice A) can exacerbate skin irritation as heat can further irritate the skin that is already sensitive due to radiation. Using perfumed soap (choice B) can further irritate the skin due to its harsh chemicals, potentially worsening skin reactions. While keeping the area moist with lotion (choice C) may seem beneficial, some lotions contain ingredients that can worsen skin reactions during radiation therapy. Therefore, avoiding sun exposure to the treated area (choice D) is the most appropriate action to prevent skin irritation and damage during radiation therapy.

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