Nursing Elites

1. A client with heart failure is receiving furosemide. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 80/min.
• B. Weight loss of 1.1 kg (2.5 lb) in 24 hours.
• C. Potassium level of 3.8 mEq/L.
• D. Urine output of 60 mL/hr.

Correct answer: B

Rationale: A weight loss of 1.1 kg (2.5 lb) in 24 hours may indicate dehydration or fluid imbalance, which should be reported. This rapid weight loss could be a sign of excessive diuresis, potentially leading to hypovolemia or electrolyte imbalances. Monitoring weight changes is crucial in clients with heart failure receiving diuretics. The other findings are within normal ranges and expected in a client receiving furosemide for heart failure. A heart rate of 80/min, a potassium level of 3.8 mEq/L, and a urine output of 60 mL/hr are generally acceptable in this scenario.

2. A nurse is assessing a client who is postoperative following a hip arthroplasty. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 90/min
• B. Redness and warmth in the calf
• C. Oxygen saturation of 95%
• D. Temperature of 37.3°C (99.1°F)

Correct answer: B

Rationale: Redness and warmth in the calf can indicate a blood clot, specifically deep vein thrombosis (DVT), which is a serious complication post hip arthroplasty. The warmth and redness are signs of inflammation due to the clot formation. DVT can lead to a pulmonary embolism if not addressed promptly. Monitoring for this complication is crucial in postoperative care. Elevated heart rate, oxygen saturation within normal limits, and a slightly elevated temperature are common findings postoperatively and may not be alarming in the absence of other concerning symptoms.

3. A nurse is caring for a client who has experienced a stroke and has aphasia. Which of the following communication strategies should the nurse use?

• A. Speak louder to help the client understand
• B. Speak using simple sentences and gestures
• C. Use a picture board to facilitate communication
• D. Have the client practice writing words down

Correct answer: C

Rationale: The correct answer is to use a picture board to facilitate communication. Aphasia can make it challenging for individuals to understand and use language. Using a picture board can help the client convey their needs and understand information more effectively. Speaking louder (A) may not be helpful as aphasia is not related to hearing loss. While speaking using simple sentences and gestures (B) can be beneficial, using a picture board (C) is a more concrete and visual method to support communication for individuals with aphasia. Having the client practice writing words down (D) may not be suitable if the client's expressive language skills are impaired due to aphasia.

4. A charge nurse is teaching new staff members about factors that increase a client's risk of becoming violent. Which of the following risk factors should the nurse include as the best predictor of future violence?

• A. Experiencing delusions.
• B. Male gender.
• C. Previous violent behavior.
• D. A history of being in prison.

Correct answer: C

Rationale: The correct answer is C: Previous violent behavior. This is the best predictor of future violence as individuals who have a history of violent behavior are more likely to engage in violent acts in the future. While experiencing delusions and being male may contribute to an increased risk of violence in certain situations, they are not as strong predictors as a history of violence. Similarly, having a history of being in prison may indicate a higher likelihood of violence, but it is not as directly linked to future violent behavior as previous violent actions.

5. A nurse is caring for a client who has depression and reports taking St. John's wort along with citalopram. The nurse should monitor the client for which of the following conditions as a result of an interaction between these substances?

• A. Serotonin syndrome
• B. Tardive dyskinesia
• C. Pseudo-parkinsonism
• D. Acute dystonia

Correct answer: A

Rationale: The correct answer is A: Serotonin syndrome. When a client takes St. John's wort, a herbal supplement, along with citalopram, a selective serotonin reuptake inhibitor (SSRI), there is a risk of developing serotonin syndrome. Serotonin syndrome is a potentially life-threatening condition characterized by symptoms such as confusion, agitation, fever, sweating, shivering, tremors, muscle rigidity, and in severe cases, seizures and coma. It is crucial for the nurse to monitor the client for these symptoms. Choices B, C, and D are incorrect because tardive dyskinesia is associated with long-term use of antipsychotic medications, pseudo-parkinsonism is a side effect of antipsychotic medications like haloperidol, and acute dystonia is a side effect of antipsychotic medications characterized by sustained muscle contractions.

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