Nursing Elites

1. A nurse is caring for a client who has diabetes insipidus and is receiving desmopressin. Which of the following findings indicates the medication is effective?

• A. The client's urine output decreases.
• B. The client's blood pressure increases.
• C. The client's heart rate increases.
• D. The client's urine specific gravity decreases.

Correct answer: A

Rationale: The correct answer is A: 'The client's urine output decreases.' Desmopressin is used to treat diabetes insipidus by reducing excessive urine output. Therefore, a decrease in urine output indicates that the medication is effectively controlling the symptoms. Choices B, C, and D are incorrect because desmopressin primarily affects urine output, not blood pressure, heart rate, or urine specific gravity.

2. A client has deep vein thrombosis (DVT). Which of the following interventions should the nurse include in the plan of care?

• A. Apply cold compresses to the affected extremity.
• B. Massage the affected extremity every 2 hours.
• C. Elevate the affected extremity above the level of the heart.
• D. Keep the affected extremity dependent when sitting.

Correct answer: C

Rationale: The correct intervention for a client with deep vein thrombosis (DVT) is to elevate the affected extremity above the level of the heart. This position promotes venous return, reduces swelling, and helps prevent complications such as pulmonary embolism. Applying cold compresses (choice A) can vasoconstrict blood vessels, potentially worsening the condition. Massaging the affected extremity (choice B) can dislodge the clot and lead to serious complications. Keeping the affected extremity dependent when sitting (choice D) can hinder venous return and exacerbate the DVT.

3. Which electrolyte imbalance is most concerning in a patient on furosemide?

• A. Hyperkalemia
• B. Hypokalemia
• C. Hyponatremia
• D. Hypercalcemia

Correct answer: B

Rationale: The correct answer is Hypokalemia. Furosemide is a loop diuretic that can lead to potassium depletion by increasing its excretion in the urine. Hypokalemia is a common and concerning side effect of furosemide therapy. Hyperkalemia (Choice A) is less likely as furosemide tends to lower potassium levels. Hyponatremia (Choice C) is more commonly seen with thiazide diuretics. Hypercalcemia (Choice D) is not directly associated with furosemide use.

4. A nurse is caring for a client who has a new diagnosis of deep-vein thrombosis (DVT). Which of the following actions should the nurse take?

• A. Massage the affected leg to relieve discomfort
• B. Place a heating pad on the affected leg
• C. Encourage the client to walk around frequently
• D. Monitor the client's oxygen saturation level

Correct answer: D

Rationale: The correct answer is to monitor the client's oxygen saturation level. Deep-vein thrombosis (DVT) increases the risk of pulmonary embolism, a life-threatening complication. Monitoring oxygen saturation helps in early detection of any signs of compromised respiratory function. Massaging the affected leg can dislodge a blood clot, leading to severe consequences. Applying heat through a heating pad can promote vasodilation and increase the risk of clot dislodgment. While mobility is essential in preventing DVT complications, encouraging excessive walking without proper assessment can potentially dislodge a clot and worsen the condition.

5. A client with bipolar disorder and experiencing mania is under the care of a nurse. Which intervention should the nurse include in the plan?

• A. Encourage the client to spend time in the day room.
• B. Withdraw the client's TV privileges if they do not attend group therapy.
• C. Encourage the client to take frequent rest periods.
• D. Place the client in seclusion when they exhibit signs of anxiety.

Correct answer: C

Rationale: Encouraging the client to take frequent rest periods is an appropriate intervention for managing mania in a client with bipolar disorder. During a manic episode, individuals often have increased energy levels, decreased need for sleep, and may engage in high-risk behaviors. Encouraging regular rest periods can help reduce stimulation and promote relaxation, which may assist in stabilizing mood. Choices A and B are not as effective in managing manic symptoms, as they do not directly address the client's need for rest and relaxation. Choice D is inappropriate because placing the client in seclusion can increase feelings of anxiety and agitation, worsening the manic episode.

Similar Questions