Nursing Elites

1. Which instruction should the nurse provide to an elderly client who is taking an ACE inhibitor and a calcium channel blocker?

• A. Wear long-sleeved clothing when outdoors
• B. Report the onset of sore throat
• C. Eat plenty of potassium-rich food
• D. Change the position slowly

Correct answer: D

Rationale: The correct instruction for an elderly client taking both an ACE inhibitor and a calcium channel blocker is to change positions slowly. Both medications can lead to orthostatic hypotension, a sudden drop in blood pressure when changing positions, which can increase the risk of falls. Instructing the client to change positions slowly helps prevent falls. Wearing long-sleeved clothing when outdoors does not directly relate to the medication combination. Reporting the onset of a sore throat is important for monitoring potential side effects but is not specific to these medications. While potassium levels should be monitored with ACE inhibitors, eating plenty of potassium-rich foods without guidance can lead to hyperkalemia, a potential side effect of ACE inhibitors.

2. A client diagnosed with tuberculosis (TB) is placed on drug therapy with rifampin (Rifadin). The client should be instructed to report which effect(s) of the medication to the healthcare provider?

• A. Reddish-orange discoloration of body fluids
• B. Bloody or blood-tinged urine
• C. Blurring of vision
• D. Weight gain of more than 2 pounds in a week

Correct answer: A

Rationale: The correct answer is A. Rifampin (Rifadin) commonly causes a reddish-orange discoloration of body fluids, including urine, sweat, saliva, and tears. This is a harmless side effect but should be reported to the healthcare provider for monitoring. Choices B, C, and D are not typically associated with rifampin therapy. Bloody or blood-tinged urine may indicate other issues such as urinary tract infection or kidney problems, blurring of vision may suggest eye problems, and significant weight gain could be related to various health conditions unrelated to rifampin.

3. A client who has had three spontaneous abortions is requesting information about possible causes. The nurse's response should be based on which information?

• A. Chromosomal abnormalities are the most common cause of early spontaneous abortions
• B. Incompetent cervix can cause spontaneous abortions
• C. An infection can cause spontaneous abortions
• D. Nutritional deficiencies are the most common cause of early spontaneous abortions

Correct answer: A

Rationale: The correct answer is A: Chromosomal abnormalities are the most common cause of early spontaneous abortions. Spontaneous abortions, also known as miscarriages, often occur due to chromosomal abnormalities in the fetus. These abnormalities are a common cause of early pregnancy loss. Choice B is incorrect because an incompetent cervix typically leads to late miscarriages, not early spontaneous abortions. Choice C is incorrect as while infections can be a cause of spontaneous abortions, they are not the most common cause. Choice D is incorrect as nutritional deficiencies are not the most common cause of early spontaneous abortions.

4. When caring for a laboring client whose contractions are occurring every 2 to 3 min, the nurse should document that the pump is infusing how many ml/hr?

• A. 42
• B. 50
• C. 60
• D. 70

Correct answer: A

Rationale: To calculate the infusion rate, we first need to determine the frequency of contractions per hour. If contractions are occurring every 2 to 3 minutes, this corresponds to 20 to 30 contractions in an hour (60 minutes). The average is 25 contractions in an hour. The pump should be infusing 1 ml for each contraction, so the infusion rate should be 25 ml/hr. Therefore, the correct answer is 42 ml/hr. Choices B, C, and D are incorrect as they do not align with the calculation based on the given data.

5. A client with a history of congestive heart failure (CHF) is admitted with fluid volume overload. Which assessment finding should the nurse report to the healthcare provider?

• A. Weight gain of 2 pounds in 24 hours
• B. Presence of a cough
• C. Edema in the lower extremities
• D. Shortness of breath

Correct answer: D

Rationale: The correct answer is 'D - Shortness of breath.' In a client with congestive heart failure experiencing fluid volume overload, shortness of breath is a critical finding that indicates possible pulmonary congestion and worsening heart failure. This symptom requires immediate attention to prevent further complications. Choices A, B, and C are common findings in clients with CHF but are not as urgent as shortness of breath. Weight gain may indicate fluid retention, cough can be due to pulmonary congestion, and edema in lower extremities is a common manifestation of CHF, but none of these findings are as concerning as shortness of breath in this scenario.

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