Nursing Elites

1. A nurse is caring for a client who is receiving IV diltiazem for atrial fibrillation. Which of the following findings is a contraindication to the administration of diltiazem?

• A. Hypotension
• B. Tachycardia
• C. Decreased level of consciousness
• D. History of diuretic use

Correct answer: A

Rationale: The correct answer is A: Hypotension. Diltiazem can cause further lowering of blood pressure, so it should not be administered if the client is already hypotensive. Monitoring blood pressure is crucial before giving diltiazem. Choice B, tachycardia, is not a contraindication for diltiazem use; in fact, diltiazem is used to slow down the heart rate. Choice C, decreased level of consciousness, may indicate other issues but is not a direct contraindication for diltiazem. Choice D, history of diuretic use, is not a contraindication by itself; however, caution should be exercised when diltiazem is given with diuretics due to potential interactions.

2. A nurse is providing teaching to a client who has tuberculosis (TB) and is prescribed rifampin. Which of the following statements should the nurse include in the teaching?

• A. This medication can cause your urine to turn a reddish-orange color.
• B. You should expect to take this medication for at least 6 months.
• C. You should avoid eating dairy products while on this medication.
• D. This medication can cause sensitivity to sunlight.

Correct answer: A

Rationale: The correct answer is A. Rifampin can cause harmless red-orange discoloration of bodily fluids, including urine, sweat, and tears. Clients should be informed about this side effect. Choice B is incorrect because the duration of rifampin therapy for TB is typically longer than 6 months. Choice C is incorrect as there is no need to avoid dairy products while on rifampin. Choice D is incorrect as rifampin does not cause sensitivity to sunlight.

3. A nurse is assessing a client with pancreatitis. Which of the following findings should the nurse look for?

• A. Increased appetite
• B. Abdominal pain
• C. Weight gain
• D. Elevated blood pressure

Correct answer: B

Rationale: The correct answer is B: Abdominal pain. Abdominal pain, often severe, is a hallmark sign of pancreatitis. Other common symptoms include nausea, vomiting, and tenderness in the abdomen. Choices A, C, and D are incorrect because increased appetite, weight gain, and elevated blood pressure are not typically associated with pancreatitis. Therefore, the nurse should primarily focus on assessing for abdominal pain in a client with suspected pancreatitis.

4. During a change-of-shift assessment, a nurse is evaluating four clients. Which finding should the nurse report to the provider first?

• A. A client with cystic fibrosis who has a productive cough and reports thirst
• B. A client with gastroenteritis who is lethargic and confused
• C. A client with diabetes mellitus whose blood glucose is 185 mg/dL
• D. A client with sickle cell anemia who reports pain 15 minutes after receiving analgesics

Correct answer: B

Rationale: Lethargy and confusion in a client with gastroenteritis are concerning findings that may indicate severe dehydration or electrolyte imbalance, requiring immediate intervention. While the other options are important, they do not pose an immediate life-threatening risk compared to the altered mental status in a client with gastroenteritis.

5. A nurse is giving discharge instructions to a client who has a new ileostomy. The nurse should recognize that the teaching has been effective when the client states:

• A. I will make sure my medications are enteric-coated
• B. My stoma will drain liquid continuously
• C. I will change my pouch system every two weeks
• D. My stoma size will stay the same after it heals

Correct answer: B

Rationale: The correct answer is B. When a client with an ileostomy states that their stoma will drain liquid continuously, it indicates an understanding of the expected outcome. In an ileostomy, the stoma continuously drains liquid stool as it bypasses the large intestine where water is absorbed. Choices A, C, and D are incorrect because ensuring medications are enteric-coated, changing the pouch system every two weeks, and expecting the stoma size to remain the same after healing are not accurate statements related to an ileostomy.

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