Nursing Elites

1. A client with osteoarthritis is prescribed acetaminophen. What is the most important teaching the nurse should provide?

• A. Take the medication with food to improve absorption.
• B. Avoid taking other pain medications to prevent liver damage.
• C. Take acetaminophen on an empty stomach to prevent stomach upset.
• D. Monitor liver function tests regularly to detect any liver damage.

Correct answer: B

Rationale: The correct answer is B. Acetaminophen can cause liver damage if taken in excessive amounts or in combination with other medications containing acetaminophen. Clients should be advised to avoid other pain medications to prevent liver toxicity. Choice A is incorrect because acetaminophen is usually taken with or without food, not specifically on an empty stomach. Choice C is incorrect because taking acetaminophen with food can help prevent stomach upset. Choice D is incorrect because while monitoring liver function tests is important for long-term acetaminophen use, the most crucial teaching is to avoid other pain medications to prevent liver damage.

2. A client is receiving IV fluid therapy for dehydration. Which assessment finding indicates that the client's fluid status is improving?

• A. Urine output increases to 50 mL/hour
• B. Client reports feeling more thirsty
• C. Blood pressure decreases from 120/80 to 110/70
• D. Heart rate increases from 80 to 100 beats per minute

Correct answer: A

Rationale: An increase in urine output is a positive sign that the client's hydration status is improving. It indicates that the kidneys are functioning well and that fluid therapy is effective. Increased urine output helps to eliminate excess fluid and waste products from the body. Choices B, C, and D are incorrect. Feeling more thirsty (choice B) is a sign of dehydration, not improvement. A decrease in blood pressure (choice C) and an increase in heart rate (choice D) are not typically indicative of improving fluid status during IV fluid therapy for dehydration.

3. The nurse is caring for a client with fluid overload. The most reliable indicator of fluid volume status is

• A. Body weight
• B. Intake and output
• C. Daily weight
• D. Skin turgor

Correct answer: C

Rationale: Daily weight is the most reliable indicator of fluid volume status as it reflects changes in body fluid balance accurately. Body weight alone can fluctuate due to various factors, including food intake and bowel movements, which may not accurately represent fluid status. Intake and output provide information on fluid balance over time but may not reflect immediate changes. Skin turgor is a physical assessment finding that indicates hydration status, not overall fluid volume status.

4. A client with peripheral artery disease reports pain while walking. What intervention should the nurse recommend?

• A. Encourage the client to increase physical activity.
• B. Instruct the client to take rest breaks during walking.
• C. Apply warm compresses to the legs to improve circulation.
• D. Massage the affected leg to relieve the pain.

Correct answer: B

Rationale: Clients with peripheral artery disease often experience claudication (leg pain during walking) due to decreased blood flow. Encouraging rest breaks during walking helps to manage pain and improve circulation. Rest breaks allow the muscles to recover from ischemia caused by inadequate blood supply. Increasing physical activity without breaks may worsen the symptoms. Applying warm compresses can potentially lead to burns or skin damage in individuals with compromised circulation. Massaging the affected leg is contraindicated in peripheral artery disease as it can further compromise blood flow.

5. A client is diagnosed with Meniere's disease. Which problem should the nurse identify as most important in the plan of care?

• A. Social isolation related to hearing loss
• B. Risk for injury related to vertigo
• C. Impaired verbal communication
• D. Impaired hearing related to ear disease

Correct answer: B

Rationale: Vertigo is the primary symptom of Meniere's disease and can lead to falls and other injuries. Ensuring safety and addressing the risk of injury is the nurse's top priority. While social isolation and impaired hearing are significant concerns associated with Meniere's disease, the immediate danger of falls due to vertigo takes precedence in the plan of care. Impaired verbal communication, although important, is not as urgent as preventing injuries caused by vertigo.

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