Nursing Elites

1. A nurse is caring for a client who has a new prescription for an antidepressant. The client reports experiencing dry mouth. Which of the following instructions should the nurse give the client?

• A. Decrease fluid intake.
• B. Chew sugarless gum.
• C. Avoid using mouthwash.
• D. Increase intake of dairy products.

Correct answer: B

Rationale: The correct answer is to instruct the client to chew sugarless gum. Chewing sugarless gum can help alleviate dry mouth by stimulating saliva production, which is a common side effect of many antidepressants. Decreasing fluid intake (choice A) is not recommended as it can worsen dry mouth. Avoiding mouthwash (choice C) is not as effective as chewing gum in stimulating saliva. Increasing intake of dairy products (choice D) is not directly related to managing dry mouth caused by antidepressants.

2. A client is experiencing suicidal thoughts and states, 'Why not end my misery?' What is the best response by the nurse?

• A. Why do you think your life isn’t worth living anymore?
• B. Do you have a plan to end your life?
• C. I need to understand what you mean by misery.
• D. You can trust me to share your thoughts.

Correct answer: B

Rationale: The correct answer is B: 'Do you have a plan to end your life?' When a client expresses suicidal thoughts, it is crucial to assess the immediate risk. Inquiring about a specific plan can help determine the seriousness of the situation. Choice A is less direct and may not provide a clear indication of the immediate risk. Choice C focuses on the interpretation of 'misery' rather than assessing the risk of suicide. Choice D offers support but does not address the critical assessment of the client's immediate safety.

3. A client is being taught about the use of metformin. Which of the following should be included?

• A. It is taken with food
• B. It can cause hyperglycemia
• C. It should be taken once daily
• D. It is an injectable medication

Correct answer: A

Rationale: Corrected Rationale: Metformin should be taken with food to minimize gastrointestinal side effects. Choice A is the correct answer as taking metformin with meals can help reduce the likelihood of experiencing gastrointestinal side effects like diarrhea and nausea, which are common side effects of metformin. Choice B is incorrect because metformin actually helps lower blood sugar levels and does not cause hyperglycemia. Choice C is incorrect as metformin is usually taken twice or even three times a day, not just once daily. Choice D is incorrect because metformin is an oral medication, not an injectable one.

4. A nurse is caring for a client who had a stroke and is showing signs of dysphagia. Which of the following findings should the nurse recognize as an indication of this condition?

• A. Abnormal movements of the mouth
• B. Inability to stand without assistance
• C. Paralysis of the right arm
• D. Loss of appetite

Correct answer: A

Rationale: Abnormal movements of the mouth are a common indication of dysphagia, a condition that impairs swallowing function. In clients who have had a stroke, dysphagia can increase the risk of aspiration, leading to serious complications. Inability to stand without assistance (Choice B) is more indicative of motor deficits following a stroke rather than dysphagia. Paralysis of the right arm (Choice C) is a manifestation of hemiplegia, which is common in stroke but not directly related to dysphagia. Loss of appetite (Choice D) may occur in individuals with dysphagia but is not a direct indicator of the condition itself.

5. While assessing the IV infusion site of a client who reports pain at the site, a nurse notes redness and warmth along the vein. What should the nurse do?

• A. Continue the infusion
• B. Increase the infusion rate
• C. Discontinue the infusion
• D. Apply a cold compress

Correct answer: C

Rationale: The symptoms described indicate phlebitis, which is inflammation of the vein. In this case, the nurse should discontinue the infusion to prevent further complications. Continuing the infusion or increasing the rate can exacerbate the condition. Applying a cold compress is not recommended for phlebitis; instead, a warm compress can help alleviate discomfort.

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