Nursing Elites

1. A nurse is planning care for a client who has a history of falls. Which of the following actions should the nurse include in the plan of care?

• A. Keep all four side rails up.
• B. Ensure the client's bed is in the lowest position.
• C. Use nonskid footwear while ambulating.
• D. Place a bedside commode close to the client's bed.

Correct answer: C

Rationale: The correct answer is C: 'Use nonskid footwear while ambulating.' This action is crucial in preventing falls in clients with a history of falls as it provides better traction and stability while walking. Choice A, 'Keep all four side rails up,' is not recommended as it can lead to client restraint and is not a fall prevention strategy. Choice B, 'Ensure the client's bed is in the lowest position,' is important for preventing injuries from falls out of bed but does not directly address fall prevention during ambulation. Choice D, 'Place a bedside commode close to the client's bed,' is a good practice for toileting safety but does not specifically address preventing falls while walking.

2. A nurse is caring for a client who has a history of alcohol use disorder and is experiencing withdrawal. Which of the following medications should the nurse expect to administer?

• A. Metoclopramide
• B. Lorazepam
• C. Haloperidol
• D. Methadone

Correct answer: B

Rationale: Lorazepam is the correct medication to administer in this situation. It is used to manage the symptoms of alcohol withdrawal and prevent complications like seizures and delirium tremens. Metoclopramide is primarily used to treat gastrointestinal issues, Haloperidol is an antipsychotic medication used for conditions like schizophrenia, and Methadone is typically used in managing opioid dependence. These medications are not the first-line treatment for alcohol withdrawal.

3. A nurse is assessing a client who is 48 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

• A. Serosanguineous drainage on the surgical dressing.
• B. Temperature of 37.8°C (100°F).
• C. Urine output of 75 mL in the past 4 hours.
• D. WBC count of 15,000/mm³.

Correct answer: D

Rationale: The correct answer is D. An elevated WBC count can indicate a potential infection, especially in a postoperative client. This finding should be reported to the provider for further evaluation and management. Choices A, B, and C are common occurrences in postoperative clients and may not necessarily indicate a severe issue. Serosanguineous drainage on the surgical dressing is a normal finding in the immediate postoperative period. A temperature of 37.8°C (100°F) can be a mild fever, which is common postoperatively due to the body's response to tissue injury. Urine output of 75 mL in the past 4 hours may be within normal limits for a postoperative client, especially if they are still recovering from anesthesia.

4. A healthcare provider is assessing a child who is being treated for bacterial pneumonia. The provider notes an increase in the child's glucose level. The provider should identify this finding as an adverse effect of which of the following medications?

• A. Methylprednisolone.
• B. Ondansetron.
• C. Guaifenesin.
• D. Amoxicillin.

Correct answer: A

Rationale: Correct. Methylprednisolone, a corticosteroid, can lead to increased glucose levels as an adverse effect. Ondansetron is an antiemetic and does not typically cause elevated glucose levels. Guaifenesin is an expectorant and is not associated with raising glucose levels. Amoxicillin is an antibiotic and does not affect glucose levels.

5. A client has a new prescription for spironolactone. Which of the following instructions should the nurse include?

• A. Take this medication with a potassium supplement.
• B. Avoid foods that contain potassium.
• C. Limit your fluid intake while taking this medication.
• D. Take this medication on an empty stomach.

Correct answer: B

Rationale: The correct answer is B because spironolactone is a potassium-sparing diuretic, which means it helps the body retain potassium. Instructing the client to avoid foods high in potassium helps prevent hyperkalemia, a potential side effect of spironolactone. Choice A is incorrect because taking spironolactone with a potassium supplement can increase the risk of hyperkalemia. Choice C is not directly related to spironolactone use. Choice D is also incorrect as spironolactone does not need to be taken on an empty stomach.

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