Nursing Elites

1. The nurse is caring for a client with a diagnosis of major depressive disorder who has been prescribed fluoxetine (Prozac). What is the most important teaching point?

• A. Take the medication with or without food.
• B. Report any increase in suicidal thoughts.
• C. Avoid foods high in tyramine.
• D. Expect improvement within 24 hours.

Correct answer: B

Rationale: The correct teaching point is to instruct the client to report any increase in suicidal thoughts. This is crucial because SSRIs like fluoxetine can initially increase suicidal ideation, especially at the beginning of treatment. Choice A is corrected to emphasize that fluoxetine can be taken with or without food. Choice C is unrelated as it pertains more to MAOIs than SSRIs like fluoxetine. Choice D is inaccurate as antidepressants like fluoxetine may take weeks to show significant improvement in symptoms, not within 24 hours.

2. A client is admitted with a diagnosis of myocardial infarction (MI). Which intervention is a priority during the acute phase?

• A. Administer morphine for pain relief
• B. Encourage the client to perform isometric exercises
• C. Position the client flat in bed
• D. Restrict fluid intake

Correct answer: A

Rationale: During the acute phase of a myocardial infarction (MI), the priority intervention is to administer morphine for pain relief. Morphine not only alleviates pain but also reduces myocardial oxygen demand, which is crucial in the management of MI. Encouraging the client to perform isometric exercises (choice B) can increase myocardial oxygen demand and should be avoided during the acute phase. Positioning the client flat in bed (choice C) may worsen symptoms by increasing venous return and workload on the heart. Restricting fluid intake (choice D) is not a priority intervention during the acute phase of MI; maintaining adequate hydration is important for organ perfusion.

3. A client complains of pain at the IV site. Upon assessment, the nurse notes the site is warm, red, and swollen. What is the most likely cause of these findings?

• A. Phlebitis
• B. Infiltration
• C. Allergic reaction
• D. Fluid overload

Correct answer: A

Rationale: The correct answer is A, Phlebitis. Phlebitis is the inflammation of a vein, often caused by irritation from an IV catheter, resulting in warmth, redness, and swelling at the site. Infiltration (choice B) refers to the leaking of IV fluids into the surrounding tissues, causing swelling and pallor, not redness and warmth like in the scenario described. An allergic reaction (choice C) would present with itching, hives, or anaphylaxis, rather than localized warmth, redness, and swelling. Fluid overload (choice D) typically manifests as generalized edema, shortness of breath, and weight gain, not localized symptoms at the IV site.

4. What is the homeostatic cellular transport mechanism that moves water from a hypotonic to a hypertonic fluid space?

• A. Filtration
• B. Diffusion
• C. Osmosis
• D. Active transport

Correct answer: C

Rationale: The correct answer is C: Osmosis. Osmosis is the homeostatic cellular transport mechanism that moves water from a hypotonic to a hypertonic fluid space to maintain cellular balance. In osmosis, water moves across a semi-permeable membrane from an area of low solute concentration (hypotonic) to an area of high solute concentration (hypertonic). This process helps regulate the water content inside cells. Choices A, B, and D are incorrect. Filtration involves the movement of solutes and solvents through a membrane due to a pressure difference, diffusion is the movement of solutes from an area of high concentration to low concentration, and active transport requires energy to move substances against their concentration gradient.

5. How should the nurse assess for cyanosis in a client with dark skin who is in respiratory distress?

• A. Abnormal skin color changes in a client with dark skin cannot be determined
• B. Blanching the soles of the feet in a client with dark skin reveals cyanosis
• C. The lips and mucus membranes of a client with dark skin are dusky in color
• D. Cyanosis in a client with dark skin is seen in the sclera

Correct answer: C

Rationale: Observing the lips and mucous membranes provides a reliable indicator of cyanosis in clients with dark skin tones. Choice A is incorrect because cyanosis can be assessed in clients with dark skin by observing other body areas. Choice B is incorrect as blanching the soles of the feet is not a relevant method for assessing cyanosis. Choice D is incorrect as cyanosis is not typically seen in the sclera in clients with dark skin.

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