Nursing Elites

1. A nurse is assessing a client who is experiencing auditory hallucinations. What question should the nurse ask?

• A. Do you understand the voices are not real?
• B. Why do you think the voices are talking to you?
• C. Have you tried going to a quiet place when this occurs?
• D. What helps you ignore the voices?

Correct answer: D

Rationale: Exploring strategies to ignore the hallucinations can help clients manage symptoms.

2. A nurse is caring for a client who has pneumonia. Which of the following findings should the nurse identify as an indication of the effectiveness of the treatment?

• A. Respiratory rate of 24/min
• B. White blood cell count of 15,000/mm3
• C. SpO2 of 95%
• D. Clear breath sounds

Correct answer: D

Rationale: Clear breath sounds are an essential indicator of effective pneumonia treatment as they suggest resolution of the lung infection. A normal respiratory rate (A) indicates adequate breathing but does not directly reflect the effectiveness of pneumonia treatment. An elevated white blood cell count (B) is a sign of infection and may not decrease immediately with treatment. While maintaining an SpO2 of 95% (C) is crucial for oxygenation, it may not directly indicate the effectiveness of pneumonia treatment.

3. A client with diabetes mellitus is receiving teaching from a nurse about foot care. Which of the following instructions should the nurse include?

• A. Soak your feet in warm water daily.
• B. Wear cotton socks.
• C. Use a heating pad to warm your feet.
• D. Trim toenails straight across.

Correct answer: D

Rationale: The correct answer is to trim toenails straight across. This instruction is crucial for clients with diabetes to prevent ingrown toenails, which can lead to infection. Soaking feet in warm water daily can increase the risk of skin breakdown. Cotton socks are recommended, but the priority in foot care for diabetes is proper nail trimming. Using a heating pad can also pose a burn risk for individuals with reduced sensation in their feet.

4. A healthcare professional is preparing to administer enoxaparin to a client. Which of the following actions should the healthcare professional take?

• A. Administer the medication intramuscularly.
• B. Inject the medication into the lateral abdominal wall.
• C. Massage the injection site after administration.
• D. Discard the prefilled syringe after expelling the air bubble.

Correct answer: B

Rationale: The correct answer is to inject the medication into the lateral abdominal wall when administering enoxaparin. This is the recommended technique to ensure proper absorption and prevent tissue damage. Choice A is incorrect because enoxaparin should be administered subcutaneously, not intramuscularly. Choice C is incorrect as massaging the injection site after administration is not recommended, as it can cause bruising and discomfort. Choice D is incorrect because the prefilled syringe should not be discarded after expelling the air bubble; it should be used for the injection.

5. 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.

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