Nursing Elites

1. A nurse is assessing a client who has a history of seizure disorder and is receiving phenytoin. Which of the following findings should the nurse identify as an adverse effect of the medication?

• A. Bradycardia.
• B. Ataxia.
• C. Tachycardia.
• D. Insomnia.

Correct answer: B

Rationale: The correct answer is B: Ataxia. Ataxia, which refers to uncoordinated movements, is a common adverse effect of phenytoin, a medication used to manage seizure disorders. Bradycardia (Choice A) is not typically associated with phenytoin; instead, it may cause tachycardia (Choice C) as a side effect. Insomnia (Choice D) is not a common adverse effect of phenytoin.

2. A nurse is assessing a client who is 1 day postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

• A. Blood pressure of 110/70 mm Hg
• B. Heart rate of 88/min
• C. Respiratory rate of 20/min
• D. Temperature of 37.3°C (99.1°F)

Correct answer: D

Rationale: The correct answer is D because a temperature of 37.3°C (99.1°F) is slightly elevated, indicating a possible infection or inflammatory response, which should be reported to the provider for further evaluation. Choices A, B, and C are within normal limits for a client postoperative, so they do not require immediate reporting. Elevated temperature can be a sign of infection or other complications, making it a priority for reporting and further assessment.

3. What is the most important nursing action for a patient experiencing a deep vein thrombosis (DVT)?

• A. Administer anticoagulants
• B. Encourage ambulation
• C. Apply compression stockings
• D. Monitor oxygen saturation

Correct answer: A

Rationale: Administering anticoagulants is the most crucial nursing action for a patient experiencing a deep vein thrombosis (DVT). Anticoagulants help prevent further clot formation and reduce the risk of complications such as pulmonary embolism. Encouraging ambulation, applying compression stockings, and monitoring oxygen saturation are important interventions in managing DVT, but administering anticoagulants takes priority as it directly targets the clotting process and prevents clot progression.

4. A nurse is caring for a client who has a prescription for a high-protein diet. Which of the following foods should the nurse recommend?

• A. Almonds
• B. Cheddar cheese
• C. Chicken breast
• D. Pasta

Correct answer: C

Rationale: Chicken breast is an excellent choice for a high-protein diet as it is a lean source of protein. Almonds, while a good source of protein, also contain high amounts of fat. Cheddar cheese is high in protein but also high in saturated fat. Pasta is not a significant source of protein compared to chicken breast.

5. A healthcare provider is providing discharge instructions to a client who has a new prescription for metformin. Which of the following instructions should the healthcare provider include?

• A. Take this medication with meals.
• B. Avoid consuming alcohol while taking this medication.
• C. Take this medication at bedtime.
• D. Report any muscle pain to your healthcare provider.

Correct answer: B

Rationale: The correct answer is B: 'Avoid consuming alcohol while taking this medication.' Clients taking metformin should avoid alcohol as it increases the risk of lactic acidosis. Choice A is incorrect because metformin is usually taken with meals to reduce gastrointestinal side effects. Choice C is incorrect as metformin is typically taken with meals, not at bedtime. Choice D is incorrect because muscle pain is not a common side effect of metformin.

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