Nursing Elites

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

• A. I should expect dark tarry stools.
• B. I should expect increased bruising.
• C. I will not get as many infections.
• D. I will expect the color of my urine to be amber.

Correct answer: A

Rationale: The correct answer is A. When taking ferrous sulfate, dark tarry stools can occur as a common side effect due to the iron content in the medication. This is a normal response to the medication and not a cause for concern. Choices B, C, and D are incorrect because increased bruising, reduced infections, and amber-colored urine are not expected side effects of ferrous sulfate.

2. How should a healthcare professional assess a patient's pain who is non-verbal?

• A. Looking for changes in vital signs that may indicate pain
• B. Using alternative methods like touch or distraction
• C. Using a pain scale appropriate for non-verbal patients
• D. Observing for facial expressions or other non-verbal cues

Correct answer: A

Rationale: When assessing pain in non-verbal patients, looking for changes in vital signs that may indicate pain is crucial. While using alternative methods like touch or distraction can be helpful, they may not directly indicate the presence of pain. Using a pain scale appropriate for non-verbal patients is important, but it may not always provide immediate feedback. Observing for facial expressions or other non-verbal cues can be subjective and may not always accurately reflect the level of pain the patient is experiencing. Therefore, monitoring vital signs is a more objective way to assess pain in non-verbal patients.

3. Which of the following clients requiring crutches should a nurse teach about how to use a three-point gait?

• A. A client who has a right femur fracture with no weight-bearing on the affected leg
• B. A client who has bilateral leg braces due to paralysis of the lower extremities
• C. A client who has bilateral knee replacements with partial weight-bearing on both legs
• D. A client who is able to bear full weight on both lower extremities

Correct answer: A

Rationale: A three-point gait is recommended for clients who are non-weight bearing on one leg. In this case, a client with a right femur fracture requiring no weight-bearing on the affected leg would benefit from learning how to use a three-point gait. Choices B, C, and D are incorrect because they involve clients who have varying degrees of weight-bearing ability on both legs, which would not require the use of a three-point gait.

4. The nurse is caring for a patient who is susceptible to infection. Which instruction will the nurse include in an educational session to decrease the risk of infection?

• A. Teaching the patient to take a temperature
• B. Teaching the patient to select nutritious foods
• C. Teaching the patient about the effects of alcohol
• D. Teaching the patient about fall prevention

Correct answer: B

Rationale: The correct answer is B: Teaching the patient to select nutritious foods. A nutritious diet plays a crucial role in strengthening the body's immune system, making it more capable of fighting off infections. Vitamins, minerals, and other nutrients found in healthy foods support immune function and overall health. Teaching the patient about taking a temperature (choice A) may be important for monitoring for signs of infection but does not directly decrease the risk of infection. Teaching about the effects of alcohol (choice C) and fall prevention (choice D) are important aspects of patient education but are not directly related to decreasing the risk of infection in a susceptible patient.

5. Which of the following is a common manifestation of opioid withdrawal?

• A. Bradycardia and hypotension
• B. Tremors and increased blood pressure
• C. Severe muscle weakness and fatigue
• D. Severe hallucinations and delusions

Correct answer: B

Rationale: The correct answer is B: Tremors and increased blood pressure. During opioid withdrawal, individuals commonly experience symptoms such as tremors, increased blood pressure, and restlessness. Choice A, which suggests bradycardia and hypotension, is incorrect as opioid withdrawal often leads to tachycardia (rapid heart rate) and increased blood pressure. Choice C, severe muscle weakness and fatigue, is not a typical manifestation of opioid withdrawal. Choice D, severe hallucinations and delusions, is more characteristic of conditions like delirium tremens associated with alcohol withdrawal, rather than opioid withdrawal.

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