Nursing Elites

1. A client with a history of hypertension is prescribed hydrochlorothiazide (HCTZ). Which adverse effect should the nurse monitor for?

• A. Hyperkalemia
• B. Hyponatremia
• C. Bradycardia
• D. Hyperglycemia

Correct answer: B

Rationale: The correct answer is 'B. Hyponatremia.' Hydrochlorothiazide can lead to electrolyte imbalances, such as hyponatremia, due to its diuretic effect. This potential adverse effect should be closely monitored in patients taking HCTZ. Choice A, hyperkalemia, is less likely to occur with HCTZ as it tends to cause hypokalemia. Choice C, bradycardia, is not a common adverse effect of HCTZ. Choice D, hyperglycemia, is also less commonly associated with HCTZ use compared to hyponatremia.

2. The nurse is assessing a client with a suspected diagnosis of deep vein thrombosis (DVT). Which clinical sign is most indicative of DVT?

• A. Redness and warmth over the affected area
• B. Decreased peripheral pulses
• C. Cyanosis of the toes
• D. Muscle cramps in the calf

Correct answer: A

Rationale: Corrected Rationale: Redness and warmth over the affected area are classic signs of inflammation, which commonly occur in deep vein thrombosis (DVT) due to the obstruction of blood flow. These symptoms result from the body's inflammatory response to the blood clot. Choices B, C, and D are less indicative of DVT. Decreased peripheral pulses may occur in arterial insufficiency rather than DVT. Cyanosis of the toes indicates decreased oxygenation and is more characteristic of arterial issues. Muscle cramps in the calf are nonspecific and can be caused by various conditions, not solely DVT.

3. What is the primary function of neutrophils?

• A. Heparin secretion
• B. Transport oxygen
• C. Phagocytotic action
• D. Antibody formation

Correct answer: C

Rationale: The correct answer is C: Phagocytotic action. Neutrophils are key components of the immune system, primarily involved in the phagocytosis of bacteria and other pathogens. Choice A, Heparin secretion, is incorrect as heparin is primarily secreted by mast cells and basophils. Choice B, Transport oxygen, is incorrect as this is mainly the function of red blood cells. Choice D, Antibody formation, is incorrect as antibody production is primarily carried out by B lymphocytes.

4. A terminally ill male client and his family request hospice care after discharge. What aspect of care should the nurse indicate is the focus of hospice?

• A. Enhance symptom management to improve end-of-life quality
• B. Facilitate assisted suicide with the client's consent
• C. Offer ways to postpone the death experience at home
• D. Provide training for family members to care for the client

Correct answer: A

Rationale: The correct answer is A. Hospice care focuses on enhancing symptom management to improve the end-of-life quality for terminally ill patients and their families. Hospice aims to provide comfort, dignity, and support during the end-of-life journey. Choice B is incorrect as hospice care does not involve assisted suicide but focuses on providing palliative care. Choice C is incorrect as hospice care does not aim to postpone the death experience but rather to provide support and comfort during this time. Choice D is incorrect as while hospice care may involve educating family members on caring for the client, the primary focus is on symptom management and quality of life.

5. A client with chronic obstructive pulmonary disease (COPD) is struggling to breathe. What should the nurse do first?

• A. Increase the oxygen flow rate according to the prescription
• B. Encourage the client to perform pursed-lip breathing
• C. Prepare for emergency intubation
• D. Assess the client's oxygen saturation and breath sounds

Correct answer: D

Rationale: The correct first action for a nurse when a client with COPD is struggling to breathe is to assess the client's oxygen saturation and breath sounds. This initial assessment is crucial in determining the severity of the client's condition and the appropriate intervention. Increasing the oxygen flow rate without proper assessment can potentially be harmful, as COPD clients have a risk of retaining carbon dioxide. Encouraging pursed-lip breathing can be beneficial but should come after assessing the client's current status. Emergency intubation is a drastic measure and should only be considered after a comprehensive assessment indicates the need for it.

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