Nursing Elites

1. A nurse is caring for a client prescribed hydroxychloroquine. Which of the following should the nurse monitor?

• A. Liver function tests
• B. Eye exams
• C. Blood glucose levels
• D. Complete blood count

Correct answer: B

Rationale: The correct answer is B: Eye exams. Hydroxychloroquine can cause retinal damage, making it essential for the nurse to monitor the client's eyes regularly for any changes. Monitoring liver function tests (choice A), blood glucose levels (choice C), or complete blood count (choice D) are not directly associated with the potential side effects of hydroxychloroquine.

2. The nurse instructs the patient about incentive spirometry as part of preoperative teaching. Which phase of the nursing process does this illustrate?

• A. Assessment
• B. Planning
• C. Implementation
• D. Evaluation

Correct answer: C

Rationale: Instructing a patient about incentive spirometry falls under the implementation phase of the nursing process. During this phase, nursing interventions are put into action. Assessment (choice A) involves collecting data about the patient's condition, planning (choice B) involves setting goals and creating a care plan, and evaluation (choice D) involves assessing the outcomes of nursing interventions. Therefore, the correct answer is C, as it reflects the active teaching and intervention part of the process.

3. A nurse is performing a newborn assessment and notes a soft, swollen area on the newborn's scalp that does not cross the suture line. Which of the following should the nurse document?

• A. Cephalohematoma
• B. Caput succedaneum
• C. Subdural hematoma
• D. Molding

Correct answer: A

Rationale: The correct answer is A, cephalohematoma. A cephalohematoma is a collection of blood between the periosteum and the skull that does not cross the suture line. It is caused by trauma during birth and typically resolves on its own. Choice B, caput succedaneum, is characterized by diffuse edema over a newborn's scalp that crosses suture lines. Choice C, subdural hematoma, is a more serious condition involving bleeding between the dura mater and the brain. Choice D, molding, refers to the shaping of the fetal head during passage through the birth canal. Therefore, the nurse should document cephalohematoma in this scenario as it aligns with the description of a soft, swollen area on the newborn's scalp that does not cross the suture line.

4. A healthcare professional is assessing a client for signs of depression. Which of the following findings should the healthcare professional look for?

• A. Increased energy
• B. Changes in sleep patterns
• C. Weight loss
• D. Both B and C

Correct answer: D

Rationale: When assessing a client for signs of depression, healthcare professionals should look for changes in sleep patterns and weight loss. These are common symptoms associated with depression. Increased energy (choice A) is not typically a sign of depression, as individuals with depression often experience fatigue and a lack of energy. Therefore, choices A, B, and C are incorrect, making choice D the correct answer.

5. A home health nurse is carefully planning care for a client with Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?

• A. Place a daily calendar in the kitchen
• B. Replace buttoned clothing with zippered items
• C. Replace carpet with hardwood floors
• D. Create variation in the daily routine

Correct answer: A

Rationale: Placing a daily calendar in the kitchen is essential for clients with Alzheimer's disease as it helps in orienting them to time and day, providing structure, and minimizing confusion in their daily routine. This action supports cognitive function and independence. Choice B is incorrect as it does not directly address cognitive orientation. Choice C is not a priority in the care plan and may not significantly impact the client's daily functioning. Choice D, creating variation in the daily routine, can actually increase confusion and anxiety in clients with Alzheimer's disease who thrive on predictability and structure.

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