Nursing Elites

1. A client receiving codeine for pain every 4 to 6 hours over 4 days. Which assessment should the nurse perform before administering the next dose?

• A. Auscultate the bowel sounds.
• B. Palpate the ankles for edema.
• C. Observe the skin for bruising.
• D. Measure the body temperature.

Correct answer: A

Rationale: The correct answer is A: Auscultate the bowel sounds. Codeine is known to cause constipation, so it is essential to assess bowel sounds before administering another dose to monitor for potential constipation or bowel motility issues. Palpating the ankles for edema (Choice B) is not directly related to codeine use or its side effects. Observing the skin for bruising (Choice C) is important but not specifically associated with codeine administration. Measuring body temperature (Choice D) is not a priority assessment related to codeine use; monitoring for constipation is more critical in this case.

2. The nurse is preparing a teaching plan for a client diagnosed with asthma. The primary purpose of the plan is to

• A. Prevent respiratory infections
• B. Prevent airway inflammation
• C. Maintain an open airway
• D. Avoid allergens that trigger attacks

Correct answer: D

Rationale: Avoiding allergens that trigger asthma attacks is crucial in managing the condition and preventing exacerbations. While preventing respiratory infections and maintaining an open airway are important aspects of asthma management, the primary focus of the teaching plan is to help the client identify and avoid allergens that could trigger asthma attacks. This proactive approach can significantly reduce the frequency and severity of asthma symptoms.

3. A client with rheumatoid arthritis is prescribed methotrexate. What is the most important teaching point for the nurse to provide?

• A. Take the medication with food to avoid gastrointestinal upset.
• B. Monitor for signs of infection, such as a sore throat.
• C. Increase fluid intake to prevent dehydration.
• D. Avoid direct sunlight to prevent photosensitivity.

Correct answer: D

Rationale: The most important teaching point for a client prescribed methotrexate is to avoid direct sunlight to prevent photosensitivity. Methotrexate can make the skin more sensitive to sunlight, increasing the risk of sunburn and skin damage. Choices A, B, and C are important aspects of client care but are not specifically related to the side effect of photosensitivity caused by methotrexate.

4. A client with hyperthyroidism is experiencing palpitations. What intervention should the nurse implement?

• A. Encourage the client to rest and limit activity.
• B. Administer a beta-blocker to reduce heart rate.
• C. Encourage the client to drink cool fluids.
• D. Provide the client with a cool environment.

Correct answer: B

Rationale: In clients with hyperthyroidism experiencing palpitations, administering a beta-blocker is the appropriate intervention. Beta-blockers help reduce heart rate and control symptoms in hyperthyroidism. Encouraging rest (Choice A) may be helpful but does not directly address the palpitations. Drinking cool fluids (Choice C) and providing a cool environment (Choice D) are more focused on temperature regulation and comfort, which are not the primary interventions for palpitations in hyperthyroidism.

5. The nurse is reviewing the laboratory results of a client with chronic kidney disease. The client's serum calcium level is 7.5 mg/dL. Which condition should the nurse suspect?

• A. Hypercalcemia
• B. Hyperkalemia
• C. Hyponatremia
• D. Hypocalcemia

Correct answer: D

Rationale: A serum calcium level of 7.5 mg/dL is indicative of hypocalcemia, a common complication in clients with chronic kidney disease due to impaired calcium absorption and metabolism. Hypercalcemia (Choice A) is the opposite of the condition presented in the question and is characterized by elevated serum calcium levels. Hyperkalemia (Choice B) is an increased potassium level, not related to the client's serum calcium level. Hyponatremia (Choice C) is a decreased sodium level and is also not related to the client's serum calcium level.

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