Nursing Elites

1. A nurse is caring for a client with a new prescription for furosemide. Which of the following should the nurse monitor?

• A. Serum potassium levels
• B. Liver function
• C. Blood glucose levels
• D. Calcium levels

Correct answer: A

Rationale: Corrected Rationale: When a client is prescribed furosemide, the nurse should monitor serum potassium levels. Furosemide is a loop diuretic that can lead to potassium loss, potentially causing hypokalemia. Monitoring serum potassium levels is crucial to prevent complications such as cardiac dysrhythmias. Choices B, C, and D are incorrect because furosemide primarily affects potassium excretion rather than liver function, blood glucose levels, or calcium levels.

2. A nurse is teaching a client who is taking prednisone about the adverse effects of this medication. Which of the following should the nurse emphasize?

• A. Weight gain
• B. Insomnia
• C. Hyperglycemia
• D. Hypertension

Correct answer: C

Rationale: The correct adverse effect of prednisone that the nurse should emphasize is hyperglycemia. Prednisone is known to increase blood sugar levels, leading to hyperglycemia. While weight gain and other metabolic changes are possible side effects, hyperglycemia is a more critical concern due to the risk of uncontrolled blood sugar levels and its impact on overall health. Insomnia and hypertension are not typically associated with prednisone use, making them less relevant to emphasize during client education.

3. A nurse should teach which of the following clients requiring crutches about how to use a three-point gait?

• A. A client who is able to bear full weight on both lower extremities.
• B. A client who has bilateral leg braces due to paralysis of the lower extremities.
• C. A client who has a right femur fracture with no weight bearing on the affected leg.
• D. A client who has bilateral knee replacements with partial weight bearing on both legs.

Correct answer: C

Rationale: The correct answer is C because a three-point gait is used when the client can bear full weight on one foot and uses crutches and the uninvolved leg to ambulate. Choices A, B, and D are incorrect because they do not meet the criteria for using a three-point gait. Choice A states that the client can bear full weight on both lower extremities, which does not require a three-point gait. Choice B mentions bilateral leg braces due to paralysis, which would not involve using a three-point gait. Choice D describes a client with bilateral knee replacements with partial weight bearing, which also does not align with the use of a three-point gait.

4. A nurse is caring for a client who has a deep vein thrombosis (DVT). Which of the following interventions should the nurse include in the plan of care?

• A. Encourage the client to ambulate frequently.
• B. Apply warm, moist compresses to the affected leg.
• C. Massage the affected leg.
• D. Place the client in a supine position.

Correct answer: B

Rationale: The correct intervention for a client with deep vein thrombosis (DVT) is to apply warm, moist compresses to the affected leg. This helps alleviate pain and improve circulation in the affected area, aiding in the treatment of DVT. Encouraging the client to ambulate frequently (Choice A) is contraindicated as it can dislodge the clot and lead to complications. Massaging the affected leg (Choice C) is also contraindicated as it can dislodge the clot and potentially cause an embolism. Placing the client in a supine position (Choice D) is not specifically indicated for DVT treatment; elevation of the affected leg is preferred over placing the client completely supine.

5. A nurse is assessing a newborn who was born vaginally with vacuum extractor assistance. The nurse notes swelling over the newborn's head that crosses the suture line. The nurse should identify the swelling as which of the following findings?

• A. Nevus simplex
• B. Caput succedaneum
• C. Cephalohematoma
• D. Erythema toxicum

Correct answer: B

Rationale: Caput succedaneum is the correct answer. It is the swelling of the soft tissues of the head that crosses suture lines, often resulting from pressure during delivery, especially with vacuum extraction. Nevus simplex (Choice A) is a pink or red birthmark that is flat and usually fades on its own. Cephalohematoma (Choice C) is a collection of blood between a baby's skull and the periosteum, often caused by birth trauma. Erythema toxicum (Choice D) is a common rash in newborns that is benign and typically resolves on its own. In this case, the description of swelling over the newborn's head crossing the suture line is characteristic of caput succedaneum, which is a common finding in newborns after vaginal delivery.

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