Nursing Elites

1. A client has been admitted to the hospital with severe diarrhea. The nurse should monitor the client for which complication?

• A. Metabolic acidosis
• B. Metabolic alkalosis
• C. Hyperkalemia
• D. Hypercalcemia

Correct answer: A

Rationale: Severe diarrhea can lead to metabolic acidosis due to the loss of bicarbonate. When there is excessive loss of bicarbonate through diarrhea, the pH of the blood decreases, leading to metabolic acidosis. Metabolic alkalosis (Choice B) is not typically associated with severe diarrhea as it involves elevated pH and bicarbonate levels. Hyperkalemia (Choice C) is less likely with severe diarrhea as potassium is often lost along with fluids. Hypercalcemia (Choice D) is not a common complication of severe diarrhea; instead, hypocalcemia may occur due to malabsorption of calcium.

2. A client with a history of hypertension is prescribed a beta-blocker. Which side effect should the nurse monitor for in this client?

• A. Increased appetite
• B. Dry mouth
• C. Nausea and vomiting
• D. Bradycardia

Correct answer: D

Rationale: The correct answer is D: Bradycardia. Beta-blockers are known to decrease heart rate, which can lead to bradycardia. This is a common side effect that nurses should monitor for in clients taking beta-blockers. Choices A, B, and C are incorrect because increased appetite, dry mouth, nausea, and vomiting are not typical side effects associated with beta-blockers. Therefore, the nurse should focus on monitoring for bradycardia in this client.

3. Which goal is most appropriate for a patient who has had a total hip replacement?

• A. The patient will ambulate briskly on the treadmill by the time of discharge.
• B. The patient will walk 100 feet using a walker by the time of discharge.
• C. The nurse will assist the patient to ambulate in the hall 2 times a day.
• D. The patient will ambulate by the time of discharge.

Correct answer: B

Rationale: The goal 'The patient will walk 100 feet using a walker by the time of discharge' is the most appropriate goal for a patient who has had a total hip replacement because it is specific, measurable, achievable, and individualized. This goal sets a clear target for the patient's mobility progress post-surgery. Choice A is too vague and does not provide a specific target distance or method of ambulation. Choice C focuses on the nurse's actions rather than the patient's progress. Choice D lacks specificity in terms of distance or assistance required, making it less measurable and individualized compared to Choice B.

4. Which action is most important for maintaining sterility when donning sterile gloves?

• A. Maintain thumbs at a ninety-degree angle.
• B. Hold hands with fingers pointing downward while gloving.
• C. Keep gloved hands above the elbows.
• D. Put the glove on the dominant hand first.

Correct answer: C

Rationale: The most crucial action for maintaining sterility when donning sterile gloves is to keep gloved hands above the elbows. This practice is essential to prevent potential contamination and maintain a sterile field. Choices A, maintaining thumbs at a ninety-degree angle, and B, holding hands with fingers pointing downward while gloving, are not as critical as keeping hands above the elbows for maintaining sterility. Choice D, putting the glove on the dominant hand first, is not as important as ensuring that gloved hands are kept above the elbows to maintain sterility.

5. A nurse is caring for a client who has herpes zoster. The client asks about complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies?

• A. Acupuncture
• B. Massage therapy
• C. Aromatherapy
• D. Herbal supplements

Correct answer: A

Rationale: The correct answer is A, Acupuncture. Acupuncture is contraindicated for clients with herpes zoster due to the risk of infection at the needle sites. In individuals with herpes zoster, the skin's integrity is compromised, increasing susceptibility to infections. Therefore, acupuncture, which involves inserting needles into the skin, can introduce pathogens and lead to local infections. Massage therapy (B), aromatherapy (C), and herbal supplements (D) do not involve skin penetration like acupuncture and are generally considered safe complementary therapies for pain control in clients with herpes zoster.

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