Nursing Elites

1. A nurse is reviewing information about advance directives with a newly admitted client. Which statement by the client indicates an understanding of the teaching?

• A. My family can make decisions if I am unable to.
• B. I have a living will that outlines my wishes when I am unable to make a decision.
• C. I can write down my wishes, but they aren't legally binding.
• D. I don't need to worry about this until I’m critically ill.

Correct answer: B

Rationale: Choice B is the correct answer because having a living will is a legal document that outlines a client's wishes when they are unable to make decisions, indicating a good understanding of advance directives. Choice A is incorrect because it doesn't mention a specific document like a living will. Choice C is incorrect because advance directives, like a living will, can be legally binding. Choice D is incorrect because planning for advance directives should ideally be done before a person becomes critically ill.

2. When educating a client about valproic acid, which instruction is essential?

• A. Monitor for rash
• B. Expect weight loss
• C. Consider it safe during pregnancy
• D. Purchase it over-the-counter

Correct answer: A

Rationale: The correct answer is to instruct the client to monitor for rash. Valproic acid can lead to severe skin rashes, and patients must be vigilant to report any rash promptly. Choice B is incorrect as valproic acid is more likely to cause weight gain. Choice C is incorrect because valproic acid is associated with birth defects and should be avoided during pregnancy. Choice D is incorrect as valproic acid is a prescription medication and not available over-the-counter.

3. A client has been prescribed lithium for bipolar disorder. Which of the following should the nurse teach the client to monitor for signs of toxicity?

• A. Nausea and vomiting
• B. Increased urination
• C. Tremors
• D. Blurred vision

Correct answer: C

Rationale: The correct answer is C: Tremors. Lithium toxicity can present with symptoms such as tremors, nausea, and blurred vision. Tremors are a common early sign of lithium toxicity and should be monitored closely. While nausea and vomiting can also occur with lithium toxicity, tremors are more specific to lithium toxicity. Increased urination is not typically associated with lithium toxicity, and blurred vision is less common compared to tremors in this context.

4. A nurse is caring for a client receiving oxytocin IV for labor augmentation. The client’s contractions are occurring every 45 seconds and lasting 90 seconds. What action should the nurse take?

• A. Discontinue the oxytocin infusion
• B. Increase the oxytocin infusion
• C. Decrease the oxytocin infusion
• D. Maintain the oxytocin infusion

Correct answer: A

Rationale: In this scenario, the client is experiencing uterine hyperstimulation with contractions every 45 seconds lasting 90 seconds. This frequency and duration of contractions can lead to fetal distress. The appropriate nursing action is to discontinue the oxytocin infusion immediately to prevent complications. Increasing or maintaining the oxytocin infusion would exacerbate the situation, while decreasing it may not be sufficient to address the issue effectively.

5. While reviewing the medical record of a client with unstable angina, which of the following findings should the nurse report to the provider?

• A. BP 106/62 mm Hg, Temp 38°C (100.4°F), HR 112/min, Resp rate 26/min, urine output 90 mL/hr
• B. Skin is cool and moist with pallor
• C. Bilateral breath sounds with crackles heard at bases of lungs
• D. Creatinine kinase 100 units/L, C-reactive protein 0.8 mg/dL, Myoglobin 88 mcg/L

Correct answer: A

Rationale: The correct answer is A. The nurse should report these vital signs to the provider immediately as they indicate increased temperature, tachycardia, and tachypnea, which are signs of possible infection or systemic inflammatory response. This could exacerbate the client's unstable angina and needs prompt evaluation. Choices B, C, and D are not as urgent as the vital signs in option A and do not directly indicate a worsening condition in the context of unstable angina.

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