Nursing Elites

1. A nurse is planning care for a client who is receiving hemodialysis. What action should the nurse include in the plan?

• A. Withhold all medications until after dialysis.
• B. Rehydrate with dextrose 5% in water for orthostatic hypotension.
• C. Check the vascular access site for bleeding after dialysis.
• D. Give an antibiotic 30 minutes before dialysis.

Correct answer: C

Rationale: The correct action that the nurse should include in the plan for a client receiving hemodialysis is to check the vascular access site for bleeding after dialysis. This is important to prevent complications such as infection or excessive bleeding. Withholding all medications until after dialysis (Choice A) is not necessary unless specific medications need to be avoided due to the dialysis process. Rehydrating with dextrose 5% in water for orthostatic hypotension (Choice B) is not directly related to post-dialysis care. Giving an antibiotic 30 minutes before dialysis (Choice D) is not a standard practice unless there is a specific clinical indication.

2. A nurse is assessing a client who is experiencing acute pain. Which of the following manifestations should the nurse expect?

• A. Hypertension
• B. Bradycardia
• C. Diaphoresis
• D. Piloerection

Correct answer: C

Rationale: The correct answer is C: Diaphoresis. Diaphoresis, which is excessive sweating, is a common manifestation of acute pain caused by increased sympathetic nervous system activity. This response is the body's way of trying to regulate body temperature during the stress response. Choices A, B, and D are incorrect. Hypertension (Choice A) and tachycardia (not bradycardia as in Choice B) are more likely responses to acute pain due to sympathetic nervous system activation. Piloerection (Choice D), also known as goosebumps, is not a typical manifestation of acute pain.

3. A nurse is caring for a client who wears glasses. What action should the nurse take?

• A. Store the glasses in a labeled case.
• B. Clean the glasses with hot water.
• C. Clean the glasses with a paper towel.
• D. Store the glasses on the bedside table.

Correct answer: A

Rationale: The correct action for the nurse to take is to store the glasses in a labeled case. This helps prevent damage and loss of the glasses, ensuring they are kept safe when not in use. Cleaning the glasses with hot water (choice B) can damage the lenses or frames, while cleaning with a paper towel (choice C) might lead to scratches. Storing the glasses on the bedside table (choice D) increases the risk of misplacement or damage.

4. A client is receiving discharge teaching regarding a new prescription for amoxicillin. Which of the following client statements indicates an understanding of the teaching?

• A. I will take this medication until my symptoms are gone.
• B. I will take this medication until it is finished.
• C. I will take this medication on an empty stomach.
• D. I will take this medication with milk.

Correct answer: B

Rationale: The correct answer is B. It is crucial for clients to complete the entire course of antibiotics as prescribed, even if symptoms improve. This helps to ensure that the infection is fully treated and reduces the risk of developing antibiotic resistance. Choice A is incorrect because stopping the medication when symptoms disappear can lead to incomplete treatment. Choice C is incorrect as amoxicillin can be taken with or without food. Choice D is incorrect because taking amoxicillin with milk can decrease its absorption.

5. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following actions should the nurse take?

• A. Request a renewal of the prescription every 8 hours.
• B. Check the client's peripheral pulse rate every 30 minutes.
• C. Obtain a prescription for restraint within 4 hours.
• D. Document the client's condition every 15 minutes.

Correct answer: C

Rationale: Obtaining a prescription for restraint within 4 hours is the correct action when managing restraints in a client with acute mania. This timeframe ensures that the use of restraints is promptly evaluated and authorized by a healthcare provider. Requesting a renewal of the prescription every 8 hours (Choice A) is not necessary and may delay appropriate care. Checking the client's peripheral pulse rate every 30 minutes (Choice B) is important but not the immediate priority when dealing with obtaining a prescription for restraints. Documenting the client's condition every 15 minutes (Choice D) is essential for monitoring, but the priority is to secure a prescription for restraints promptly.

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