Nursing Elites

1. A nurse is teaching a client who has a new prescription for fluoxetine. Which of the following statements should the nurse include?

• A. "You should expect to feel an improvement in your symptoms within 1 week."
• B. "You may experience weight gain while taking this medication."
• C. "You should take this medication in the morning to prevent insomnia."
• D. "You should stop taking this medication if you experience dry mouth."

Correct answer: B

Rationale: The correct statement the nurse should include is that the client may experience weight gain while taking fluoxetine. Weight gain is a common side effect of fluoxetine, and patients should be informed about this potential issue. Stating that the client should expect improvement in symptoms within 1 week (Choice A) is incorrect as fluoxetine may take a few weeks to have a noticeable effect. Taking the medication in the morning to prevent insomnia (Choice C) is not necessary since fluoxetine can be taken at any time of the day. Instructing the client to stop taking the medication if experiencing dry mouth (Choice D) is misleading, as dry mouth is a common but usually not serious side effect of fluoxetine.

2. A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?

• A. Raise the side rails on both sides of the client's bed during repositioning.
• B. Reposition the client without assistive devices.
• C. Discuss the client's preferences to determine a repositioning schedule.
• D. Evaluate the client's ability to help with repositioning.

Correct answer: D

Rationale: The correct answer is to evaluate the client's ability to help with repositioning. When caring for a client who had a stroke, assessing their ability to participate in repositioning is crucial for promoting safety and encouraging their involvement in their care. This evaluation helps determine the level of assistance needed and supports the client's autonomy. Option A is incorrect because raising the side rails alone does not address the client's active involvement in repositioning. Option B is incorrect as using assistive devices may be necessary for safe repositioning. Option C is incorrect as discussing preferences is important but does not directly address the client's ability to assist in repositioning.

3. How should a healthcare professional care for a patient with a stage 2 pressure ulcer?

• A. Clean the area with normal saline
• B. Apply antibiotic ointment
• C. Use a hydrocolloid dressing
• D. Change the dressing daily

Correct answer: C

Rationale: Using a hydrocolloid dressing is the appropriate care for a stage 2 pressure ulcer because it provides a moist healing environment, promotes healing, and helps to prevent infection. Cleaning the area with normal saline (Choice A) is important but not the primary treatment for a stage 2 pressure ulcer. Applying antibiotic ointment (Choice B) may not be necessary unless there is a sign of infection. Changing the dressing daily (Choice D) may disrupt the healing process and is not recommended unless the dressing is soiled or compromised.

4. A nurse is providing discharge teaching to a client following a cholecystectomy. Which of the following instructions should the nurse include?

• A. I should avoid lifting objects heavier than 5 pounds for 1 week.
• B. I can resume my usual activities after 2 weeks.
• C. I should expect to have pain in my right shoulder.
• D. I should follow a low-protein diet for 1 week.

Correct answer: C

Rationale: The correct answer is C. Pain in the right shoulder after a cholecystectomy is common due to residual gas from the procedure. Choices A, B, and D are incorrect. It is important to avoid heavy lifting for a longer period than just 1 week to prevent complications. Resuming usual activities after 2 weeks may not be appropriate depending on the individual's recovery. Following a low-protein diet is not a standard recommendation post-cholecystectomy.

5. A nurse is reviewing the laboratory values of a client who has diabetic ketoacidosis (DKA). Which of the following findings should the nurse report to the provider?

• A. Potassium 4.2 mEq/L
• B. Glucose 250 mg/dL
• C. Bicarbonate 20 mEq/L
• D. Sodium 135 mEq/L

Correct answer: B

Rationale: The correct answer is B. A glucose level of 250 mg/dL indicates hyperglycemia, which is expected in DKA. However, in the context of DKA management, persistent or worsening hyperglycemia can indicate inadequate treatment response or complications, necessitating further monitoring and intervention. Potassium levels are crucial in DKA due to the risk of hypokalemia, but a level of 4.2 mEq/L is within the normal range. Bicarbonate levels are typically low in DKA, making a value of 20 mEq/L consistent with the condition. Sodium levels of 135 mEq/L are also within normal limits and not a priority for immediate reporting in the context of DKA.

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