Nursing Elites

1. A client begins taking an antidepressant drug during the second day of hospitalization. Which assessment is most important for the nurse to include in this client's plan of care while the client is taking the antidepressant?

• A. Appetite
• B. Mood
• C. Withdrawal
• D. Energy level

Correct answer: B

Rationale: Corrected Rationale: Monitoring the client's mood is essential when starting an antidepressant to assess for any changes or adverse effects related to the medication. Changes in mood can indicate the effectiveness of the antidepressant or potential side effects. Assessing appetite (Choice A) is important but not as crucial as monitoring mood in this context. Withdrawal symptoms (Choice C) are more relevant when discontinuing antidepressants rather than starting them. Energy level (Choice D) can be influenced by various factors and may not directly reflect the client's response to the antidepressant.

2. The nurse is providing discharge instructions to a client who had a laparoscopic cholecystectomy. What should the nurse include in the teaching?

• A. Avoid driving for at least 2 weeks
• B. Resume a low-fat diet
• C. Remove the bandages from the incision after 24 hours
• D. Expect significant pain for the first week

Correct answer: C

Rationale: The correct answer is C: 'Remove the bandages from the incision after 24 hours.' Prompt removal of bandages after 24 hours promotes proper wound healing and reduces the risk of infection. Choice A is incorrect because avoiding driving for 2 weeks may not be universally necessary post-cholecystectomy. Choice B is incorrect because while a low-fat diet is recommended after surgery, it is not directly related to incision care. Choice D is incorrect because while pain is common post-surgery, stating 'significant pain for the first week' may not apply to all patients, potentially causing unnecessary anxiety.

3. The nurse is caring for a client who has just undergone a total hip replacement. Which intervention is most important to prevent postoperative complications?

• A. Encourage early ambulation
• B. Apply ice to the surgical site
• C. Monitor the surgical site for signs of infection
• D. Administer pain medication as prescribed

Correct answer: A

Rationale: Encouraging early ambulation is crucial following a total hip replacement surgery as it helps prevent complications such as deep vein thrombosis (DVT) by promoting circulation. Early ambulation also aids in preventing pneumonia, muscle atrophy, and pressure ulcers. Applying ice to the surgical site may help with pain and swelling, but it is not as critical in preventing complications as early ambulation. While monitoring the surgical site for signs of infection is important, it is not as crucial in preventing postoperative complications compared to early ambulation. Administering pain medication as prescribed is essential for comfort and pain management but does not directly prevent postoperative complications like early ambulation does.

4. A client who is 24 weeks pregnant presents with a complaint of feeling dizzy when lying on her back. What is the best response by the nurse?

• A. Advise the client to lie on her side
• B. Encourage the client to drink more fluids
• C. Suggest the client elevate her legs when lying down
• D. Recommend the client take short walks throughout the day

Correct answer: A

Rationale: The correct answer is to advise the client to lie on her side. Lying on the side can prevent the compression of the vena cava, which can cause dizziness in pregnant women. Encouraging the client to drink more fluids (Choice B) may be beneficial for other conditions but is not the best response for dizziness when lying on her back. Suggesting the client elevate her legs when lying down (Choice C) is not directly related to the issue described by the client. Recommending the client take short walks throughout the day (Choice D) may be helpful for other pregnancy-related symptoms but is not the most appropriate action for dizziness when lying on her back.

5. The nurse is assessing a newborn and notes that the infant has a yellowish tint to the skin. What should the nurse do next?

• A. Reassure the parents that this is normal
• B. Monitor the infant's bilirubin levels
• C. Increase the frequency of feedings
• D. Administer phototherapy

Correct answer: B

Rationale: When a newborn presents with a yellowish tint to the skin, it can indicate jaundice, which is caused by elevated bilirubin levels. Monitoring the infant's bilirubin levels is crucial to assess the severity of jaundice and determine the need for further intervention. Reassuring the parents without proper assessment could lead to delayed treatment if jaundice is present. Increasing the frequency of feedings may not address the underlying cause of jaundice. Administering phototherapy is a treatment option that should be based on bilirubin level assessment and healthcare provider's recommendation.

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