Nursing Elites

1. A nurse is assessing a client who has been taking haloperidol for several years. Which of the following assessment findings should the nurse recognize as a long-term side effect of this medication?

• A. Lipsmacking
• B. Agranulocytosis
• C. Clang association
• D. Alopecia

Correct answer: A

Rationale: Lipsmacking is a common sign of tardive dyskinesia, a long-term side effect of haloperidol. Tardive dyskinesia is characterized by repetitive, involuntary, purposeless movements such as lipsmacking, tongue protrusion, and facial grimacing. Agranulocytosis (choice B) is a potential side effect of antipsychotic medications but is not specifically associated with haloperidol. Clang association (choice C) is a form of disorganized speech seen in conditions like schizophrenia but is not a side effect of haloperidol. Alopecia (choice D) refers to hair loss and is not a common long-term side effect of haloperidol.

2. When digitally evacuating stool from a client with a fecal impaction, what action should the nurse take?

• A. Insert a lubricated gloved finger and advance along the rectal wall
• B. Apply lubricant and stimulate peristalsis
• C. Apply pressure to the abdomen to assist with the removal
• D. Increase fluid intake before the procedure

Correct answer: A

Rationale: The correct action when digitally evacuating stool from a client with a fecal impaction is to insert a lubricated gloved finger and advance along the rectal wall. This technique helps prevent trauma and is the appropriate method for addressing fecal impaction. Choice B is incorrect as stimulating peristalsis will not directly assist in evacuating the impacted stool. Choice C is incorrect as applying pressure to the abdomen is not the recommended method for stool evacuation. Choice D is incorrect as increasing fluid intake does not directly aid in digitally evacuating the stool.

3. A nurse is teaching a client who has heart failure about a new prescription for furosemide. Which of the following statements should the nurse include?

• A. You should take this medication in the morning to reduce urination during the day.
• B. You may experience ringing in your ears as a side effect.
• C. This medication may cause your potassium level to decrease.
• D. You should consume foods high in potassium while taking this medication.

Correct answer: C

Rationale: The correct statement to include when teaching a client about furosemide is that it may cause potassium levels to decrease. Furosemide is a loop diuretic that can lead to hypokalemia, emphasizing the importance of monitoring potassium levels. Option A is incorrect because furosemide is usually taken in the morning to prevent nighttime diuresis. Option B is incorrect as tinnitus, not ringing in the ears, is associated with furosemide use. Option D is wrong because while it is essential to monitor potassium levels, the client should be advised to consume foods high in potassium to prevent hypokalemia.

4. A client with osteoporosis is being taught about dietary management. Which of the following foods should be recommended?

• A. Almonds
• B. Spinach
• C. Yogurt
• D. Carrots

Correct answer: C

Rationale: Yogurt is a calcium-rich food that helps strengthen bones and should be recommended to clients with osteoporosis. Almonds, spinach, and carrots do not provide as much calcium as yogurt and are not as beneficial for individuals with osteoporosis.

5. A nurse manager is planning to teach staff about critical pathways. Which of the following information should the nurse include?

• A. Critical pathways have unlimited timeframes for completion.
• B. Critical pathways are designed to decrease health care costs.
• C. Patients follow the critical pathway if variances occur.
• D. Budgets are used to create the critical pathway.

Correct answer: B

Rationale: The correct answer is B. Critical pathways are structured, multi-disciplinary plans of care designed to decrease health care costs and improve outcomes by standardizing and streamlining processes. Choice A is incorrect because critical pathways have specific timeframes for completion. Choice C is incorrect as patients are expected to follow the critical pathway without deviations to achieve optimal outcomes. Choice D is incorrect because budgets do not create critical pathways; rather, they are based on clinical guidelines and best practices.

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