Nursing Elites

1. A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following interventions should the nurse implement?

• A. Provide a low-sodium diet.
• B. Administer lorazepam as prescribed.
• C. Keep the client in a supine position.
• D. Place the client in restraints as prescribed.

Correct answer: B

Rationale: Administering lorazepam is the appropriate intervention for a client experiencing acute alcohol withdrawal. Lorazepam helps reduce agitation and prevent complications during this withdrawal phase. Choice A, providing a low-sodium diet, is not directly related to managing alcohol withdrawal symptoms. Choice C, keeping the client in a supine position, is not necessary and may not address the client's withdrawal symptoms. Choice D, placing the client in restraints, should only be considered if the client is at risk of harming themselves or others, but it is not the primary intervention for managing alcohol withdrawal.

2. A nurse is teaching a client who has a new prescription for clopidogrel. Which of the following statements should the nurse include?

• A. You should avoid drinking alcohol while taking this medication.
• B. You should monitor for signs of infection.
• C. Take this medication with food to prevent gastrointestinal upset.
• D. Take this medication with a full glass of water.

Correct answer: B

Rationale: The correct statement the nurse should include when teaching a client taking clopidogrel is to monitor for signs of infection. Clopidogrel affects platelet levels and can increase the risk of bleeding. Monitoring for signs of infection is crucial because a compromised immune system can make the client more susceptible to infections. Choices A, C, and D are incorrect because clopidogrel is not directly linked to alcohol restrictions, food requirements, or specific water intake instructions.

3. A client who has a new diagnosis of type 2 diabetes mellitus is being taught about foot care by a nurse. Which of the following statements should the nurse include?

• A. Use lotion on your feet to prevent dry, cracked skin, avoiding application between the toes.
• B. Avoid soaking your feet in warm water daily to prevent dry skin.
• C. Trim your toenails straight across to prevent injury.
• D. Do not apply a heating pad to your feet if they feel cold.

Correct answer: C

Rationale: The correct answer is C. Trimming toenails straight across is essential for clients with diabetes to prevent the risk of ingrown toenails and injury. Using lotion on feet can be beneficial but should not be applied between the toes to avoid moisture buildup, which can lead to infections. Soaking feet in warm water can lead to dry skin, increasing the risk of cracks and other complications. Applying a heating pad to feet when they feel cold is not recommended for clients with diabetes due to impaired sensation, which can result in burns and other injuries.

4. A nurse realizes that the wrong medication has been administered to a client. Which of the following actions should the nurse take first?

• A. Notify the provider
• B. Report the incident to the nurse manager
• C. Monitor vital signs
• D. Fill out an incident report

Correct answer: C

Rationale: The correct first action for the nurse to take after realizing that the wrong medication has been administered to a client is to monitor vital signs. Monitoring vital signs is crucial as it allows the nurse to promptly assess for any immediate adverse effects that may result from the wrong medication. This immediate assessment is essential for ensuring the client's safety and well-being. Notifying the provider (choice A) and reporting the incident to the nurse manager (choice B) are important steps to take, but they should come after ensuring the client's immediate safety. Filling out an incident report (choice D) is also necessary but should be done after addressing the client's immediate needs.

5. A nurse is caring for a client who has heart failure and is receiving furosemide. Which of the following findings should the nurse identify as an adverse effect of the medication?

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

Correct answer: C

Rationale: The correct answer is C: 'Hypokalemia.' Furosemide is a loop diuretic that can lead to potassium depletion (hypokalemia) due to increased urinary excretion of potassium. This can result in adverse effects such as muscle weakness, cardiac dysrhythmias, and other complications. Hyperkalemia (choice A) is not an adverse effect of furosemide but rather an elevated potassium level. Hyperglycemia (choice B) and hyponatremia (choice D) are not typically associated with furosemide use. Therefore, monitoring potassium levels and addressing hypokalemia is crucial in clients taking furosemide.

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