Nursing Elites

1. What is an expected outcome when a client is receiving an IV administration of furosemide?

• A. Increased blood pressure.
• B. Increased urine output.
• C. Decreased pain.
• D. Decreased premature ventricular contractions.

Correct answer: B

Rationale: The correct answer is B: Increased urine output. Furosemide is a loop diuretic that works by inhibiting the reabsorption of sodium and chloride in the ascending loop of Henle in the kidneys, leading to increased urine production. This diuretic effect helps to reduce fluid volume in the body, making it an expected outcome when a client is receiving furosemide. Choice A, increased blood pressure, is incorrect because furosemide typically causes a decrease in blood pressure due to its diuretic effect. Choice C, decreased pain, and choice D, decreased premature ventricular contractions, are unrelated to the pharmacological action of furosemide.

2. A nursing assistant is measuring the blood pressure (BP) of a hypertensive client while a nurse observes. Which action on the part of the assistant would interfere with accurate measurement and prompt the nurse to intervene? Select all that apply.

• A. Measuring the BP after the client has sat quietly for 5 minutes
• B. Having the client sit with the arm bared and supported at heart level
• C. Using a cuff with a rubber bladder that encircles less than 80% of the limb
• D. Measuring the BP after the client reports that he just drank a cup of coffee

Correct answer: C

Rationale: To ensure accurate blood pressure (BP) measurement, the cuff used should have a rubber bladder that encircles at least 80% of the limb being measured. This ensures proper compression and accurate readings. Choices A and B are correct practices as it is recommended to measure BP after the client has sat quietly for 5 minutes and to have the client sit with the arm bared and supported at heart level. Choice D is also a correct reason for intervention as the client should not have consumed caffeine or smoked tobacco within 30 minutes before BP measurement, as it can affect the accuracy of the reading.

3. A client who is mouth breathing is receiving oxygen by face mask. The nursing assistant asks the nurse why a water bottle is attached to the oxygen tubing near the wall oxygen outlet. The nurse responds that the primary purpose of the water is to:

• A. Prevent the client from getting a nosebleed
• B. Give the client added fluid by way of the respiratory tree
• C. Humidify the oxygen that is bypassing the client’s nose
• D. Prevent fluid loss from the lungs during mouth breathing

Correct answer: C

Rationale: The purpose of the water bottle is to humidify the oxygen that is bypassing the nose during mouth breathing. When a client breathes through the mouth, the oxygen delivered by the face mask bypasses the natural humidification provided by the nasal passages. Therefore, the water bottle attachment helps to add moisture to the oxygen, preventing dryness and irritation to the respiratory tract. Choices A, B, and D are incorrect. Clients breathing through the mouth are not at risk for nosebleeds, do not receive added fluid through the respiratory tree, and do not experience fluid loss from the lungs due to mouth breathing.

4. The client who has a history of Parkinson's disease for the past 5 years is being assessed by the nurse. What symptoms would this client most likely exhibit?

• A. Loss of short-term memory, facial tics, and grimaces, and constant writhing movements.
• B. Shuffling gait, masklike facial expression, and tremors of the head.
• C. Extreme muscular weakness, easy fatigability, and ptosis.
• D. Numbness of the extremities, loss of balance, and visual disturbances.

Correct answer: B

Rationale: Parkinson's Disease, a common neurologic progressive disorder in older clients, is characterized by symptoms such as shuffling gait, masklike facial expression, and tremors of the head and hands. Choice A is incorrect as symptoms like loss of short-term memory, facial tics, and constant writhing movements are not typically associated with Parkinson's disease. Choice C is incorrect as extreme muscular weakness, easy fatigability, and ptosis are more indicative of other conditions like myasthenia gravis. Choice D is incorrect as numbness of the extremities, loss of balance, and visual disturbances are not classic symptoms of Parkinson's disease.

5. A middle-aged adult with a family history of CAD has the following: total cholesterol 198 (11 mmol/L); LDL cholesterol 120 (6.7 mmol/L); HDL cholesterol 58 (3.2 mmol/L); triglycerides 148 (8.2 mmol/L); blood sugar 102 (5.7 mmol/L); and C-reactive protein (CRP) 4.2. The health care provider prescribes a statin medication and aspirin. The client asks the nurse why these medications are needed. Which is the best response by the nurse?

• A. The labs indicate severe hyperlipidemia and the medications will lower your LDL, along with a low-fat diet.
• B. The triglycerides are elevated and will not return to normal without these medications.
• C. The CRP is elevated indicating inflammation seen in cardiovascular disease, which can be lowered by the medications prescribed.
• D. These medications will reduce the risk of type 2 diabetes.

Correct answer: C

Rationale: CRP is a marker of inflammation, which is elevated in cardiovascular disease. Statins and aspirin help lower CRP and reduce the risk of heart attacks and strokes.

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