Nursing Elites

1. A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which action should the nurse take?

• A. Offer fluids every 2 hours.
• B. Document the client's behavior prior to being placed in seclusion.
• C. Discuss with the client their inappropriate behavior prior to seclusion.
• D. Assess the client's behavior every hour.

Correct answer: B

Rationale: The correct answer is to document the client's behavior prior to seclusion. Documenting the behavior is crucial as it helps justify the need for seclusion, provides a clear record of events leading up to the intervention, and ensures transparency in the client's care. Offering fluids every 2 hours (Choice A) is important for hydration but is not directly related to the situation of seclusion. Discussing the inappropriate behavior with the client (Choice C) may not be safe or appropriate when seclusion is necessary for preventing harm. Assessing the client's behavior every hour (Choice D) is important but may not be the most immediate action needed when seclusion is already in place.

2. A nurse is caring for a toddler who has acute lymphocytic leukemia. In which of the following activities should the toddler participate?

• A. Looking at alphabet flashcards
• B. Playing with a large plastic truck
• C. Using scissors to cut out paper shapes
• D. Watching a cartoon in the dayroom

Correct answer: B

Rationale: The correct answer is playing with a large plastic truck. This activity is suitable for toddlers as it promotes their development, encourages fine motor skills, and provides an opportunity for imaginative play. Looking at alphabet flashcards may be more suitable for older children who are learning letters and words. Using scissors to cut out paper shapes may pose a safety risk for a toddler, as they may not have the dexterity or understanding required for this activity. Watching a cartoon in the dayroom is a passive activity and does not actively engage the toddler in physical or cognitive development.

3. A client prescribed clozapine is receiving discharge teaching from a nurse. Which statement by the client indicates an understanding of the teaching?

• A. “I should report a sore throat to my provider.”
• B. “I should avoid drinking grapefruit juice while taking this medication.”
• C. “I should take this medication with food.”
• D. “I should avoid taking this medication with food.”

Correct answer: A

Rationale: The correct answer is A. Clozapine can cause agranulocytosis, a serious condition that decreases the number of white blood cells. Reporting a sore throat is crucial as it could be a sign of infection. Choice B is incorrect because there is no specific interaction between clozapine and grapefruit juice. Choice C is incorrect because clozapine is usually taken without regard to meals. Choice D is incorrect as clozapine is generally taken without food to enhance absorption.

4. What is the best method to assess for fluid overload in patients with heart failure?

• A. Monitor daily weight
• B. Check for jugular vein distention
• C. Check for pitting edema
• D. Check for fluid retention

Correct answer: A

Rationale: The correct answer is A: Monitor daily weight. Daily weight monitoring is the most accurate method to assess fluid overload in patients with heart failure. Changes in weight can indicate fluid retention before visible signs like jugular vein distention or pitting edema appear. Checking for jugular vein distention (choice B) is helpful but may not be as sensitive as daily weight monitoring. Pitting edema (choice C) and fluid retention (choice D) are signs of fluid overload, but daily weight monitoring is a more proactive approach to detect changes early.

5. A nurse is providing discharge teaching to a client who had a stroke. What instruction should the nurse provide?

• A. Avoid lifting more than 5 pounds.
• B. Perform range-of-motion exercises daily.
• C. Take medications at the same time every day.
• D. Monitor blood pressure daily.

Correct answer: C

Rationale: The correct answer is C: 'Take medications at the same time every day.' Consistency in medication administration is crucial for stroke recovery to maintain therapeutic drug levels in the body. Choice A, 'Avoid lifting more than 5 pounds,' though important to prevent strain, is not directly related to medication adherence. Choice B, 'Perform range-of-motion exercises daily,' is beneficial for overall recovery but is not specific to medication management. Choice D, 'Monitor blood pressure daily,' is important but does not address the key aspect of medication regimen adherence.

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