Nursing Elites

1. A nurse is developing a care plan for a client who is receiving nitroprusside for severe hypertension. Which action should the nurse include?

• A. Administer calcium gluconate at the bedside.
• B. Monitor blood pressure every 2 hours.
• C. Limit light exposure to the infusion.
• D. Keep the client on NPO status.

Correct answer: C

Rationale: The correct action the nurse should include in the care plan for a client receiving nitroprusside for severe hypertension is to limit light exposure to the infusion. Nitroprusside is light-sensitive, so it should be protected from light exposure to prevent degradation. Administering calcium gluconate at the bedside is not directly related to nitroprusside administration. Monitoring blood pressure every 2 hours is a good practice but is not specifically related to the administration of nitroprusside. Keeping the client on NPO status is not necessary solely based on receiving nitroprusside.

2. A nurse is caring for a client who has Crohn's disease. Which of the following findings should the nurse expect?

• A. Weight gain.
• B. Bloody stools.
• C. Urinary retention.
• D. Abdominal distention.

Correct answer: B

Rationale: The correct answer is B: Bloody stools. Bloody stools are a common symptom of Crohn's disease, characterized by inflammation of the digestive tract. Weight gain (choice A) is less likely due to malabsorption issues associated with Crohn's disease. Urinary retention (choice C) is not directly related to Crohn's disease. Abdominal distention (choice D) may occur in Crohn's disease but is not as specific a finding as bloody stools.

3. A client with rheumatoid arthritis is experiencing morning stiffness. Which of the following actions should the nurse take?

• A. Encourage the client to avoid physical activity in the morning.
• B. Encourage the client to take NSAIDs before bedtime.
• C. Apply cold packs to the affected joints in the morning.
• D. Perform passive range-of-motion exercises before getting out of bed.

Correct answer: C

Rationale: The correct action the nurse should take is to apply cold packs to the affected joints in the morning. Rheumatoid arthritis is characterized by inflammation, and applying cold packs can help reduce inflammation and stiffness in the joints. Encouraging the client to avoid physical activity in the morning (Choice A) may worsen stiffness, as movement is beneficial for joint mobility. While NSAIDs (Choice B) can help with pain and inflammation, applying cold packs directly to the affected joints is more targeted and effective. Performing passive range-of-motion exercises (Choice D) can be helpful, but applying cold packs is the priority for reducing inflammation and stiffness.

4. A healthcare professional is receiving a change-of-shift report for an adult female client who is postoperative. Which client information should the healthcare professional report?

• A. Low-grade fever.
• B. Shortness of breath.
• C. Decreased urine output.
• D. High platelet count.

Correct answer: A

Rationale: In a postoperative client, a low-grade fever can be an early sign of infection, which is crucial to report to the healthcare team for timely intervention. Shortness of breath and decreased urine output are also important to monitor, but in the context of postoperative care, infection is a more immediate concern. A high platelet count is not typically a priority in the immediate postoperative period.

5. A nurse is assessing a client who is receiving furosemide for heart failure. Which of the following findings is the priority to report to the provider?

• A. Blood pressure of 98/58 mm Hg
• B. Urine output of 50 mL/hr
• C. Serum potassium level of 3.2 mEq/L
• D. Weight loss of 0.5 kg (1.1 lb) in 24 hours

Correct answer: C

Rationale: The correct answer is C. A serum potassium level of 3.2 mEq/L indicates hypokalemia, a potential complication of furosemide therapy, and should be reported immediately. Hypokalemia can lead to serious cardiac dysrhythmias. Choices A, B, and D are important assessments but are not as critical as managing serum potassium levels in a client receiving furosemide for heart failure.

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