Nursing Elites

1. A client with schizophrenia starting therapy with clozapine is being discharged. Which symptom should the client report to the provider as the highest priority?

• A. Constipation
• B. Blurred vision
• C. Fever
• D. Dry mouth

Correct answer: C

Rationale: The correct answer is C: Fever. When a client is taking clozapine, fever can indicate serious conditions such as infection or severe reactions, which need immediate medical attention. Constipation (choice A), blurred vision (choice B), and dry mouth (choice D) are common side effects of clozapine but are not as urgent as fever. Constipation can be managed with dietary changes or medications, blurred vision can improve over time, and dry mouth can be relieved with frequent sips of water.

2. A nurse is reviewing the medical record of a client who is receiving gentamicin for a wound infection. Which of the following findings should the nurse report to the provider?

• A. Blood urea nitrogen (BUN) 25 mg/dL
• B. Serum creatinine 1.5 mg/dL
• C. Serum glucose 110 mg/dL
• D. White blood cell (WBC) count 5,000/mm3

Correct answer: A

Rationale: An elevated BUN level indicates possible nephrotoxicity, which is a side effect of gentamicin and should be reported. Elevated serum creatinine and WBC count are not specifically related to gentamicin therapy. Normal serum glucose levels are also within the expected range.

3. A nurse manager is planning to promote client advocacy among staff in a medical unit. Which of the following actions should the nurse take?

• A. Encourage staff to implement the principle of paternalism when a client is having difficulty making a choice
• B. Tell staff to explain procedures to clients before obtaining informed consent
• C. Instruct unit staff to share personal experiences to help clients make decisions
• D. Develop a system for staff members to report safety concerns in the client care environment

Correct answer: D

Rationale: The correct answer is D. Developing a system for staff members to report safety concerns in the client care environment is crucial to promoting client advocacy and ensuring client safety. This action empowers staff to identify and address potential safety issues, ultimately enhancing the quality of care provided. Choices A, B, and C are incorrect. Choice A suggests implementing paternalism, which involves making decisions for clients without their input, contradicting the principles of client advocacy. Choice B focuses on informed consent procedures, which are important but do not directly relate to promoting client advocacy among staff. Choice C, sharing personal experiences, may not always align with professional boundaries and can potentially bias clients' decision-making processes.

4. How should a healthcare professional assess a patient's pain level post-surgery?

• A. Use a pain rating scale
• B. Check vital signs
• C. Observe for non-verbal cues
• D. Check for abnormal breath sounds

Correct answer: A

Rationale: Corrected Rationale: Using a pain rating scale is the most appropriate method to assess a patient's pain level post-surgery. Pain rating scales provide a standardized way for patients to communicate their pain intensity, allowing for accurate assessment and effective pain management. Checking vital signs (choice B) is important for monitoring a patient's overall health status but may not directly reflect their pain level. Observing for non-verbal cues (choice C) is valuable, but it may not always provide a clear indication of the pain intensity. Checking for abnormal breath sounds (choice D) is relevant for assessing respiratory status but does not directly evaluate the patient's pain level.

5. A nurse is assessing a client who has just received an opioid medication. Which of the following findings should the nurse monitor first?

• A. Constipation.
• B. Drowsiness.
• C. Orthostatic hypotension.
• D. Respiratory depression.

Correct answer: D

Rationale: When a client receives an opioid medication, the nurse should first monitor for respiratory depression as it is a life-threatening adverse effect associated with opioids. This can lead to inadequate ventilation and hypoxia, requiring immediate intervention. Constipation, drowsiness, and orthostatic hypotension are also common side effects of opioids but are not as immediately life-threatening as respiratory depression.

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