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. What is the appropriate nursing intervention for a patient experiencing a suspected stroke?

• A. Administer thrombolytics
• B. Perform a neurological assessment
• C. Perform a CT scan
• D. Administer oxygen

Correct answer: B

Rationale: Performing a neurological assessment is the appropriate nursing intervention for a patient experiencing a suspected stroke. This assessment helps determine the severity of the stroke, identify potential deficits, and guide further interventions. Administering thrombolytics (Choice A) should only be done after a CT scan to confirm the type of stroke and rule out hemorrhagic stroke. Performing a CT scan (Choice C) is important but is typically done after stabilizing the patient. Administering oxygen (Choice D) is essential to maintain adequate oxygenation, but performing a neurological assessment takes precedence in the immediate management of a suspected stroke.

3. A nurse is assessing a client who is receiving enteral nutrition via a nasogastric tube. Which of the following findings should the nurse report to the provider?

• A. Gastric pH of 2.5.
• B. Bowel sounds every 4 hours.
• C. Diarrhea of 250 mL in 24 hours.
• D. Gastric residual of 150 mL.

Correct answer: D

Rationale: A gastric residual of 150 mL may indicate delayed gastric emptying and should be reported to the provider.

4. What should the healthcare provider monitor for a patient receiving furosemide?

• A. Monitor urine output
• B. Monitor blood pressure
• C. Monitor potassium levels
• D. Monitor serum creatinine

Correct answer: C

Rationale: The correct answer is to monitor potassium levels when a patient is receiving furosemide because furosemide can cause potassium depletion. It is essential to monitor potassium levels to prevent complications such as hypokalemia. While monitoring urine output is important in assessing kidney function, and monitoring blood pressure and serum creatinine are relevant in certain situations, the priority when administering furosemide is to monitor potassium levels due to the medication's potential to deplete potassium.

5. A healthcare professional is preparing to administer ceftriaxone IM to a client. Which of the following actions should the healthcare professional take?

• A. Administer the medication using a tuberculin syringe
• B. Administer the medication at a 45-degree angle
• C. Use the dorsogluteal muscle for injection
• D. Aspirate for blood return before injecting the medication

Correct answer: D

Rationale: Correct Answer: When administering intramuscular injections like ceftriaxone, it is essential to aspirate for blood return before injecting the medication to ensure that the needle is not in a blood vessel. Choices A and B are incorrect because ceftriaxone is typically administered using a syringe appropriate for IM injections (not a tuberculin syringe) and injected at a 90-degree angle rather than 45 degrees. Choice C is incorrect because the dorsogluteal site is no longer recommended for IM injections due to potential injury to the sciatic nerve and other structures.

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