Nursing Elites

1. A client with heart failure has a new prescription for furosemide. Which of the following statements should the nurse make?

• A. Taking furosemide can cause your potassium levels to be high
• B. Eat foods that are high in sodium
• C. Rise slowly when getting out of bed
• D. Taking furosemide can cause you to be overhydrated

Correct answer: C

Rationale: Educating the client on the importance of rising slowly when getting out of bed is crucial due to the risk of orthostatic hypotension associated with furosemide use. This precaution helps prevent dizziness and falls. Options A and D are incorrect as furosemide commonly causes hypokalemia and dehydration, respectively, rather than high potassium levels or overhydration. Option B is inaccurate as clients on furosemide need to reduce sodium intake to manage fluid retention.

2. During physical therapy, a client with Parkinson's disease makes the following statements. Which statement indicates the need for a referral to physical therapy?

• A. ''I have been experiencing more tremors in my left arm than before''
• B. ''I noticed that I am having a harder time holding on to my toothbrush''
• C. ''Lately, I feel like my feet are freezing up, as they are stuck to the ground''
• D. ''Sometimes, I feel I am making a chewing motion when I'm not eating''

Correct answer: C

Rationale: Feeling like the feet are freezing up and sticking to the ground is a common symptom of Parkinson's disease known as 'freezing of gait.' This symptom significantly impacts mobility and can be dangerous, indicating the need for specialized physical therapy interventions to address gait disturbances and improve mobility.

3. Which of the following is a sign or symptom of a hemolytic reaction to a blood transfusion?

• A. Hemoglobinuria
• B. Chest pain
• C. Urticaria
• D. Distended neck veins

Correct answer: A

Rationale: Hemoglobinuria is a characteristic sign of a hemolytic reaction to a blood transfusion. Hemolytic reactions can lead to the destruction of red blood cells, causing the release of hemoglobin into the urine, which presents as hemoglobinuria. Chest pain, urticaria, and distended neck veins are not specific signs of a hemolytic reaction and may be associated with other conditions or reactions.

4. A nurse is providing teaching about gastrostomy tube feedings to the parents of a school-age child. Which of the following instructions should the nurse give?

• A. Administer the feeding over 30 minutes
• B. Place the child in a supine position after the feeding
• C. Change the feeding bag and tubing every 3 days
• D. Warm the formula in a warm water bath before administration

Correct answer: B

Rationale: Administering the feeding over 30 minutes helps prevent complications such as aspiration. Placing the child in an upright position after the feeding is recommended to reduce the risk of aspiration. It is essential to change the feeding bag and tubing every 3 days to maintain asepsis and prevent infections. Warming the formula in a warm water bath is the correct method as using a microwave can create hot spots that may burn the child's mouth or throat.

5. When preparing to administer an IM injection that is irritating to the subcutaneous tissue, what is the best action to prevent tracking of the medication?

• A. Use a small gauge needle
• B. Apply ice on the injection site
• C. Administer at a 45° angle
• D. Use the Z-track technique

Correct answer: D

Rationale: The Z-track technique is the best action to prevent tracking of the medication when administering an IM injection that is irritating to the subcutaneous tissue. This technique involves pulling the skin to the side before administering the injection and then releasing the skin after the injection. By doing so, a zig-zag pathway is created, preventing the medication from leaking into the subcutaneous tissue and reducing irritation. Options A, B, and C are incorrect. Using a small gauge needle may not prevent tracking of the medication. Applying ice on the injection site or administering at a 45° angle does not specifically address preventing tracking of the medication in cases where the injection is irritating to the subcutaneous tissue.

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