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. The nurse observes that a client’s wrist restraint is secured to the side rail of the bed. What action should the nurse take?

• A. Ensure that the restraint is snug against the client’s wrist.
• B. Reposition the restraint tie onto the bedframe.
• C. Double knot the restraint to ensure safety.
• D. Leave the restraint in place and notify the healthcare provider.

Correct answer: B

Rationale: The correct action for the nurse to take is to reposition the restraint tie onto the bedframe. Restraints should always be secured to the bedframe, not the side rails, to prevent injury to the client in case the bed is adjusted. Choice A is incorrect because the issue is with the attachment point, not the snugness of the restraint. Choice C is incorrect as double knotting the restraint does not address the incorrect attachment point. Choice D is incorrect as the nurse should not leave the restraint in the wrong position; instead, it should be moved to the correct location on the bedframe.

3. During an excretory urogram, which observation made by the nurse indicates a complication?

• A. The client complains of a salty taste in the mouth when the dye is injected
• B. The client's entire body turns a bright red color
• C. The client states 'I have a feeling of getting warm.'
• D. The client gags and complains 'I am getting sick.'

Correct answer: B

Rationale: The correct answer is B because a whole-body bright red color indicates a severe reaction to the contrast dye and must be addressed immediately. Choices A, C, and D do not indicate a severe complication during an excretory urogram. Choice A is a common side effect of the dye, choice C could be a normal sensation due to the injection, and choice D may indicate nausea which is less severe compared to a whole-body red color reaction.

4. The nurse is teaching a client about postoperative care following a total knee arthroplasty. What instruction should the nurse prioritize?

• A. Begin ambulation as soon as possible.
• B. Use continuous passive motion therapy to maintain joint mobility.
• C. Avoid putting weight on the affected leg.
• D. Apply ice packs to reduce pain and swelling.

Correct answer: B

Rationale: The correct answer is B: 'Use continuous passive motion therapy to maintain joint mobility.' Continuous passive motion therapy is crucial in postoperative care following a total knee arthroplasty as it helps prevent stiffness and maintain joint mobility. Ambulation is important but should be guided and not immediate. Avoiding putting weight on the affected leg is also essential initially to prevent complications. Applying ice packs can help reduce pain and swelling, but it is not the priority instruction for maintaining joint mobility and preventing stiffness.

5. A client with Alzheimer’s disease is becoming increasingly confused. What action should the nurse take first?

• A. Reorient the client to time and place.
• B. Monitor the client’s vital signs.
• C. Provide the client with calming activities to reduce confusion.
• D. Consult with the healthcare provider about adjusting the client’s medication.

Correct answer: B

Rationale: The correct action for the nurse to take first when a client with Alzheimer’s disease is becoming increasingly confused is to monitor the client’s vital signs (Choice B). Increased confusion in Alzheimer’s disease patients may indicate underlying issues like infection, dehydration, or medication side effects. Monitoring vital signs is crucial in identifying any potential causes of the confusion. Choices A, C, and D are not the priority in this situation. Reorienting the client to time and place (Choice A) can be helpful but is not the first priority. Providing calming activities (Choice C) and consulting with the healthcare provider about medication adjustments (Choice D) may be necessary but should come after assessing the client's vital signs to rule out immediate physical causes of confusion.

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