Nursing Elites

1. A healthcare provider is assessing a client who has severe dehydration. Which finding indicates effective treatment?

• A. Sunken anterior fontanel
• B. Tenting skin turgor
• C. Flat anterior fontanel
• D. Hyperpnea

Correct answer: C

Rationale: A flat anterior fontanel indicates effective treatment for dehydration in infants. Dehydration often causes sunken fontanels, so when the anterior fontanel becomes flat, it suggests that rehydration has occurred. Sunken anterior fontanel (Choice A) is a sign of dehydration, not effective treatment. Tenting skin turgor (Choice B) is also a sign of dehydration, indicating poor skin turgor. Hyperpnea (Choice D) is increased depth and rate of breathing and is not directly related to the hydration status of the client.

2. In the nursing process, the evaluation phase is used to determine:

• A. Value of the nursing intervention
• B. Accuracy of problem identification
• C. Quality of the plan of care
• D. Degree of outcome achievement

Correct answer: D

Rationale: The evaluation phase of the nursing process is used to determine the degree of outcome achievement. It assesses whether the goals and outcomes set during the planning phase were met. Choice A is incorrect because it focuses on the worth of the intervention rather than the achievement of outcomes. Choice B is incorrect as it pertains to the assessment phase where problems are identified. Choice C is incorrect as it refers to the planning phase where the care plan is developed, not evaluated.

3. A client has been prescribed lithium for bipolar disorder. Which of the following should the nurse teach the client to monitor for signs of toxicity?

• A. Nausea and vomiting
• B. Increased urination
• C. Tremors
• D. Blurred vision

Correct answer: C

Rationale: The correct answer is C: Tremors. Lithium toxicity can present with symptoms such as tremors, nausea, and blurred vision. Tremors are a common early sign of lithium toxicity and should be monitored closely. While nausea and vomiting can also occur with lithium toxicity, tremors are more specific to lithium toxicity. Increased urination is not typically associated with lithium toxicity, and blurred vision is less common compared to tremors in this context.

4. When educating a patient about gabapentin use, what should the nurse include?

• A. It can cause sedation
• B. It can be taken with alcohol
• C. It is a pain reliever
• D. It has no side effects

Correct answer: A

Rationale: The correct answer is A: 'It can cause sedation.' Gabapentin is known to cause sedation, and patients should be advised about this side effect, especially regarding activities that require alertness. Choice B is incorrect because gabapentin should not be taken with alcohol as it can increase the risk of central nervous system depression. Choice C is incorrect because while gabapentin is used to treat nerve pain, it is not classified as a traditional pain reliever. Choice D is incorrect because gabapentin, like any medication, can have side effects, such as dizziness, drowsiness, and fatigue.

5. A healthcare provider is assessing a client with chronic obstructive pulmonary disease (COPD) receiving oxygen therapy. Which of the following findings indicates oxygen toxicity?

• A. Oxygen saturation 94%
• B. Decreased respiratory rate
• C. Wheezing
• D. Peripheral cyanosis

Correct answer: B

Rationale: The correct answer is B: Decreased respiratory rate. In clients with COPD, especially when receiving oxygen therapy, a decreased respiratory rate is indicative of oxygen toxicity. This occurs because their respiratory drive is often dependent on low oxygen levels. Oxygen saturation of 94% is within an acceptable range and does not necessarily indicate oxygen toxicity. Wheezing is more commonly associated with airway narrowing or constriction, while peripheral cyanosis is a sign of decreased oxygen levels in the peripheral tissues, not oxygen toxicity.

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