Nursing Elites

1. A patient with epilepsy is prescribed phenytoin. What is the primary side effect the nurse should monitor for?

• A. Hypotension
• B. Gingival hyperplasia
• C. Bradycardia
• D. Hyperkalemia

Correct answer: B

Rationale: Gingival hyperplasia, or overgrowth of the gums, is a common side effect of phenytoin. Patients should maintain good oral hygiene to minimize this effect.

2. A client with a history of hypertension is prescribed hydrochlorothiazide. Which instruction should the nurse include in the client's teaching?

• A. Take this medication in the morning.
• B. Avoid foods high in potassium.
• C. Monitor your blood pressure regularly.
• D. Decrease your intake of high-sodium foods.

Correct answer: C

Rationale: Regular monitoring of blood pressure is crucial for individuals with hypertension to assess the effectiveness of the prescribed medication and to ensure blood pressure is within the target range. This helps in managing hypertension and preventing complications associated with high blood pressure. Choices A, B, and D are incorrect because while taking the medication in the morning may be recommended for some drugs, it is not the key instruction for hydrochlorothiazide. Avoiding foods high in potassium and decreasing high-sodium foods are important dietary considerations for certain conditions, but they are not the immediate focus when starting hydrochlorothiazide.

3. A client with heart failure is prescribed furosemide (Lasix). Which instruction should the nurse include in the client's teaching plan?

• A. Take the medication before bedtime.
• B. Report any weight gain of more than 2 pounds in a day.
• C. Increase your intake of high-sodium foods.
• D. Limit your fluid intake to less than 1 liter per day.

Correct answer: B

Rationale: In heart failure, fluid retention is a concern. Furosemide helps manage this by promoting diuresis. Instructing the client to report weight gain exceeding 2 pounds in a day is crucial as it can indicate fluid accumulation, prompting timely intervention to prevent worsening heart failure symptoms and complications.

4. While assessing a client with preeclampsia who is receiving magnesium sulfate, the nurse notes her deep tendon reflexes are 1+, respiratory rate is 12 breaths/minute, urinary output is 90 ml in 4 hours, and magnesium sulfate level is 9 mg/dl. What intervention should the nurse implement based on these findings?

• A. Continue the magnesium sulfate infusion as prescribed.
• B. Decrease the magnesium sulfate infusion by one-half.
• C. Stop the magnesium sulfate infusion immediately.
• D. Administer calcium gluconate immediately.

Correct answer: C

Rationale: The nurse should stop the magnesium sulfate infusion immediately in a client with preeclampsia exhibiting diminished reflexes, respiratory depression, and low urinary output, which indicate magnesium sulfate toxicity. This action is crucial to prevent further complications and adverse effects on the client.

5. A 60-year-old male client is admitted to the hospital with the complaint of right knee pain for the past week. His right knee and calf are warm and edematous. He has a history of diabetes and arthritis. Which neurological assessment action should the nurse perform for this client?

• A. Glasgow Coma Scale
• B. Assess pulses, paresthesia, and paralysis distal to the right knee
• C. Assess pulses, paresthesia, and paralysis proximal to the right knee
• D. Optic nerve using an ophthalmoscope

Correct answer: B

Rationale: In this scenario, the nurse should assess pulses, paresthesia, and paralysis distal to the right knee to evaluate for neurovascular compromise. This assessment helps determine the perfusion and sensation of the lower extremity, which is crucial in identifying potential vascular or nerve damage that may be causing the client's symptoms.

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