Nursing Elites

1. A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian.

• A. A client who has a prescription for warfarin and states, 'I will need to limit how much spinach I eat.'
• B. A client who has gout and states, 'I can continue to eat anchovies on my pizza.'
• C. A client who has a prescription for spironolactone and states, 'I will reduce my intake of foods that contain potassium.'
• D. A client who has osteoporosis and states, 'I'll plan to take my calcium carbonate with a full glass of water.'

Correct answer: C

Rationale: The correct answer is C. Spironolactone is a potassium-sparing diuretic, which means it helps the body retain potassium and excrete sodium and water. Therefore, clients on spironolactone should reduce their intake of foods high in potassium to prevent hyperkalemia. Choices A, B, and D are incorrect because limiting spinach intake due to warfarin, eating anchovies with gout, and taking calcium carbonate with water for osteoporosis do not directly relate to the medication's side effects or dietary restrictions associated with spironolactone.

2. A client receiving a blood transfusion develops a fever. What action should the nurse take?

• A. Stop the transfusion immediately.
• B. Administer an antihistamine as prescribed.
• C. Administer a diuretic as prescribed.
• D. Increase the transfusion rate.

Correct answer: A

Rationale: When a client receiving a blood transfusion develops a fever, the priority action for the nurse is to stop the transfusion immediately. A fever during a blood transfusion may indicate a transfusion reaction, and stopping the transfusion is crucial to prevent further complications. Administering an antihistamine (choice B) or a diuretic (choice C) without assessing and addressing the potential transfusion reaction can be harmful. Increasing the transfusion rate (choice D) is contraindicated as it can exacerbate any adverse reactions the client is experiencing.

3. A nurse is caring for a client who is 24 hr postpartum and is breastfeeding her newborns. The client asks the nurse to warm up seaweed soup that the client's partner brought for her. Which of the following responses should the nurse make?

• A. Does the doctor know you are eating that?
• B. Why are you eating seaweed soup?
• C. Of course I will heat that up for you.
• D. The hospital food is more nutritious.

Correct answer: C

Rationale: Respecting cultural dietary preferences enhances patient-centered care.

4. A nurse is teaching a client about home care following cataract surgery. Which of the following statements should the nurse include?

• A. You should wear a protective eye shield while sleeping.
• B. You should avoid bending over to pick things up.
• C. You should apply pressure to your eye if you feel pain.
• D. You should resume wearing your regular glasses immediately.

Correct answer: A

Rationale: The correct answer is A: 'You should wear a protective eye shield while sleeping.' After cataract surgery, wearing a protective eye shield while sleeping is crucial to prevent accidental injury to the eye. Choice B is incorrect because patients should indeed avoid bending over, but it is not the most important instruction among the options provided. Choice C is incorrect because applying pressure to the eye if pain is felt can be harmful and should not be advised. Choice D is incorrect because patients should not resume wearing their regular glasses immediately post cataract surgery; they should wait until their healthcare provider permits.

5. A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the following laboratory values should the nurse monitor?

• A. Hemoglobin
• B. aPTT
• C. INR
• D. Platelet count

Correct answer: B

Rationale: The correct answer is B: aPTT. The activated partial thromboplastin time (aPTT) is monitored to assess the therapeutic effect of heparin and to adjust the infusion rate if needed. Monitoring hemoglobin levels (choice A) is important for assessing anemia but is not specific to heparin therapy. INR (choice C) is used to monitor the effects of warfarin, not heparin. Platelet count (choice D) is important to monitor for heparin-induced thrombocytopenia, but aPTT is the primary laboratory value used to monitor heparin therapy.

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