Nursing Elites

1. A nurse is teaching a client about the use of nitrofurantoin. Which of the following should be included?

• A. It can cause a brown discoloration of urine
• B. It should be taken with food
• C. It has no side effects
• D. It is safe during pregnancy

Correct answer: A

Rationale: The correct answer is A. Nitrofurantoin can cause a harmless brown discoloration of urine. Choice B is also correct as it should be taken with food to enhance absorption. Choice C is incorrect as nitrofurantoin does have side effects, such as gastrointestinal disturbances. Choice D is incorrect as nitrofurantoin is not recommended during the last month of pregnancy due to potential risks to the fetus.

2. A healthcare provider is preparing to administer a dose of levothyroxine. Which of the following should the healthcare provider do?

• A. Give it with food
• B. Assess the patient's heart rate
• C. Administer it in the evening
• D. Give it with calcium supplements

Correct answer: B

Rationale: The correct answer is to assess the patient's heart rate. Levothyroxine is a thyroid hormone replacement medication that can increase metabolism. One of the potential side effects of levothyroxine is tachycardia (rapid heart rate). Therefore, it is essential for the healthcare provider to assess the patient's heart rate before administering the medication to monitor for any signs of tachycardia. Giving levothyroxine with food may affect its absorption, so it is typically recommended to administer it on an empty stomach. Administering it in the evening is not necessary unless specifically prescribed by the healthcare provider, and giving it with calcium supplements can interfere with the absorption of levothyroxine.

3. A nurse is assessing a client 2 hours after a vaginal delivery and notes that the client's uterus is boggy and displaced to the right. Which of the following interventions should the nurse perform first?

• A. Assist the client to void
• B. Massage the uterus
• C. Administer oxytocin
• D. Encourage breastfeeding

Correct answer: A

Rationale: A boggy and displaced uterus is often a sign of bladder distention, which can prevent the uterus from contracting effectively. The priority intervention is to assist the client to void. By emptying the bladder, the uterus can return to midline and become firm. Massaging the uterus or administering oxytocin may be necessary but should come after addressing the bladder distention. Encouraging breastfeeding is important for uterine contraction but is not the priority in this situation.

4. A nurse is assessing a male adolescent client who has heart failure. Based on the client’s chart, which of the following actions should the nurse plan to take?

• A. Withhold spironolactone
• B. Administer ferrous sulfate
• C. Administer furosemide
• D. Withhold digoxin

Correct answer: C

Rationale: The correct answer is to administer furosemide. Furosemide is a diuretic commonly used in heart failure to manage fluid retention, helping alleviate symptoms like edema and shortness of breath. Withholding spironolactone, a potassium-sparing diuretic, could lead to electrolyte imbalances. Administering ferrous sulfate is used to treat iron deficiency anemia, not heart failure. Withholding digoxin, a medication used in heart failure to improve heart function, can worsen the client's condition.

5. A nurse in the emergency department is caring for a patient who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the patient’s care, the nurse should identify which of the following risks as the priority for assessment and intervention?

• A. Infection
• B. Airway obstruction
• C. Fluid imbalance
• D. Pain management

Correct answer: B

Rationale: When a patient has extensive burns involving the head, neck, and chest, the priority concern is airway obstruction. The proximity of the burns to the airway can lead to swelling and compromise the patient's ability to breathe. In this situation, ensuring a clear airway and adequate oxygenation takes precedence over other risks such as infection, fluid imbalance, or pain management. While these are also important considerations in burn care, the immediate threat to the patient's life from airway compromise makes it the priority for assessment and intervention.

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