Nursing Elites

1. A nurse is caring for a client who has been prescribed methadone. Which of the following client statements indicates a need for further teaching?

• A. I understand methadone slows my breathing.
• B. I understand methadone may cause me to have trouble sleeping.
• C. I will avoid alcohol while I’m taking this medication.
• D. I’ll change positions slowly, especially when standing.

Correct answer: B

Rationale: The correct answer is B because methadone typically causes sedation and respiratory depression, not trouble sleeping. The statement about trouble sleeping indicates a need for further teaching. Choices A, C, and D are incorrect because understanding that methadone slows breathing, avoiding alcohol while taking the medication, and changing positions slowly to prevent dizziness are all appropriate client statements when prescribed methadone.

2. Which of the following interventions is most appropriate for a client with hyperemesis gravidarum?

• A. Encourage high-calorie meals
• B. Administer intravenous fluids
• C. Provide frequent small meals
• D. Limit fluid intake

Correct answer: B

Rationale: The correct answer is B: Administer intravenous fluids. Hyperemesis gravidarum is severe, persistent nausea and vomiting during pregnancy that can lead to dehydration and electrolyte imbalances. The priority intervention is to administer intravenous fluids to maintain hydration. Encouraging high-calorie meals (Choice A) may exacerbate symptoms due to increased gastric stimulation. Providing frequent small meals (Choice C) may not be effective in severe cases where continuous vomiting occurs. Limiting fluid intake (Choice D) is contraindicated in hyperemesis gravidarum as dehydration is a significant concern.

3. A nurse is preparing to teach a client with chronic renal failure. Which dietary instruction is most appropriate?

• A. Increase calcium intake
• B. Increase potassium intake
• C. Increase protein intake
• D. Restrict protein intake

Correct answer: D

Rationale: The correct answer is to restrict protein intake for a client with chronic renal failure. In renal failure, the kidneys are unable to effectively filter waste products. Excessive protein intake can lead to the accumulation of waste products, increasing the workload on the kidneys. Therefore, restricting protein intake is essential to prevent further kidney damage. Choices A, B, and C are incorrect. Increasing calcium intake is not specifically indicated for chronic renal failure. Increasing potassium intake can be dangerous in renal failure as impaired kidneys may not be able to excrete excess potassium. Increasing protein intake is contraindicated in chronic renal failure as it can worsen kidney function and increase the accumulation of waste products.

4. A client has been prescribed phenytoin. Which of the following should the nurse monitor to prevent toxicity?

• A. Blood pressure
• B. Complete blood count
• C. Serum phenytoin levels
• D. Liver function tests

Correct answer: C

Rationale: Corrected Rationale: Serum phenytoin levels should be regularly monitored to prevent toxicity because the therapeutic range is narrow. Monitoring blood pressure (choice A), complete blood count (choice B), and liver function tests (choice D) are not directly related to preventing phenytoin toxicity.

5. A client is being educated by a nurse on how to use a PCA pump postoperatively. Which statement by the client indicates understanding?

• A. I should wait until the pain is severe before using the PCA pump.
• B. My family can press the button for me while I’m asleep.
• C. I will press the button when I start to feel pain.
• D. I will only press the button once per hour.

Correct answer: C

Rationale: The correct answer is C. This statement indicates understanding because the client recognizes that they should use the PCA pump when they start to feel pain. Waiting for the pain to become severe is not recommended as it may lead to inadequate pain control. Option B is incorrect because only the client should control the PCA pump to ensure safety and appropriate dosing. Option D is also incorrect as there is no set limit on how often the button can be pressed, as it should be used as needed when pain is felt.

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