Nursing Elites

1. What information should the nurse include in the discharge teaching plan of a client with low back pain who is taking cyclobenzaprine to control muscle spasms?

• A. Take this medication with or without food
• B. Avoid using heat or ice on injured muscles while taking this medication
• C. Use cold and allergy medications only as directed by a healthcare provider
• D. Discontinue all nonsteroidal anti-inflammatory medications

Correct answer: C

Rationale: The correct answer is C: 'Use cold and allergy medications only as directed by a healthcare provider.' It is essential to inform the client not to self-medicate with cold and allergy medications or make changes without consulting a healthcare provider to prevent potential drug interactions or adverse effects. Choice A is incorrect because cyclobenzaprine can be taken with or without food, so there is no specific requirement to take it on an empty stomach. Choice B is incorrect because using heat or ice on injured muscles while taking cyclobenzaprine is generally safe and can help with symptom management. Choice D is also incorrect because discontinuing nonsteroidal anti-inflammatory medications should be done under the guidance of a healthcare provider, but it is not a direct concern related to taking cyclobenzaprine for muscle spasms.

2. A 70-year-old client is admitted to the hospital after 24 hours of acute diarrhea. To determine fluid status, which initial data is most important for the nurse to obtain?

• A. Usual and current weight
• B. Color and amount of urine
• C. Number and frequency of stools
• D. Intake and output 24 hours prior to admission

Correct answer: A

Rationale: The correct answer is A: Usual and current weight. Weight changes are the most direct indicator of fluid status in a patient with acute diarrhea. Monitoring weight loss or gain can provide crucial information about fluid balance. Option B, color and amount of urine, though important for assessing renal function, is not as direct an indicator of fluid status as weight. Option C, number and frequency of stools, is relevant for assessing the severity of diarrhea but does not provide direct information on fluid status. Option D, intake and output 24 hours prior to admission, does not reflect the current fluid status and may not be accurate in a rapidly changing condition like acute diarrhea.

3. The nurse is preparing to administer an oral antibiotic to a client with unilateral weakness, ptosis, mouth drooping, and aspiration pneumonia. What is the priority nursing assessment that should be done before administering this medication?

• A. Ask the client about soft food preferences
• B. Auscultate the client’s breath sounds
• C. Obtain and record the client’s vital signs
• D. Determine which side of the body is weak

Correct answer: B

Rationale: The correct answer is to auscultate the client’s breath sounds. Assessing breath sounds is crucial in this scenario as it helps ensure that the client can safely swallow the oral antibiotic without aspirating. Unilateral weakness, ptosis, mouth drooping, and aspiration pneumonia indicate potential swallowing difficulties, making it essential to assess breath sounds for any signs of respiratory issues. Asking about food preferences (choice A) may be relevant later but is not the priority before administering the medication. While obtaining vital signs (choice C) is important, assessing breath sounds takes precedence in this case. Determining which side of the body is weak (choice D) is not the priority assessment before administering the oral antibiotic.

4. An adult suffered burns to the face and chest resulting from a grease fire. On admission, the client was intubated, and a 2-liter bolus of normal saline was administered IV. Currently, the normal saline is infusing at 250 ml/hour. The client’s heart rate is 120 beats/minute, blood pressure is 90/50 mmHg, respirations are 12 breaths/minute over the ventilated 12 breaths for a total of 24 breaths/minute, and the central venous pressure (CVP) is 4 mm H2O. Which intervention should the nurse implement?

• A. Increase the rate of normal saline infusion
• B. Infuse an additional bolus of normal saline
• C. Lower the head of the bed to a recumbent position
• D. Bring a tracheostomy tray to the bedside

Correct answer: B

Rationale: The correct intervention is to infuse an additional bolus of normal saline. The client's presentation with a heart rate of 120 beats/minute, hypotensive blood pressure of 90/50 mmHg, and low CVP of 4 mm H2O indicates hypovolemic shock. Administering more normal saline can help in restoring intravascular volume and improving perfusion. Increasing the rate of normal saline infusion (Choice A) is not the best choice as it may lead to fluid overload. Lowering the head of the bed to a recumbent position (Choice C) could worsen hypotension by reducing venous return. Bringing a tracheostomy tray to the bedside (Choice D) is not a priority at this time as the client is already intubated, and the immediate concern is addressing the hypovolemia.

5. A client diagnosed with a deep vein thrombus (DVT) followed by a diagnosis of pulmonary embolism (PE) is receiving heparin via an infusion pump at a rate of 1400 u/hour. The client tells the nurse, “I wish this medicine would hurry up and dissolve this clot in my lung so that I can go home”. What response is best for the nurse to provide?

• A. Heparin prevents further clot formation, but your risk of bleeding needs to be monitored closely
• B. You seem to be concerned about the length of time it takes for Heparin to dissolve this clot
• C. Let me contact your healthcare provider to discuss the possibility of receiving IV heparin therapy at home
• D. Why are you so anxious to leave the hospital when you know you are not well enough yet?

Correct answer: A

Rationale: The correct response is A: 'Heparin prevents further clot formation, but your risk of bleeding needs to be monitored closely.' Heparin is an anticoagulant that prevents further clot formation, but it does not quickly dissolve existing clots. It is crucial for the nurse to educate the client about the purpose of heparin and the necessity for close monitoring of bleeding risks. Choice B is incorrect as it does not address the misunderstanding about heparin's mechanism of action. Choice C is incorrect as home administration of IV heparin therapy requires careful consideration and should not be suggested without a thorough assessment. Choice D is incorrect as it does not address the client's misconception about heparin's role in dissolving clots and instead focuses on the client's desire to leave the hospital.

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