Nursing Elites

1. A client who has a new prescription for lithium is receiving teaching from a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. ''I will avoid eating foods that contain tyramine.''
• B. ''I should increase my salt intake while taking this medication.''
• C. ''I should drink at least 2 liters of water each day while taking this medication.''
• D. ''I should avoid consuming caffeinated beverages while taking this medication.''

Correct answer: C

Rationale: The correct answer is C. Drinking at least 2 liters of water daily is crucial for clients taking lithium to prevent dehydration and lithium toxicity. Lithium is a salt, so it's important for clients to maintain adequate hydration. Option A is incorrect because lithium does not interact with tyramine-containing foods. Option B is incorrect because increasing salt intake is not necessary and can actually exacerbate lithium toxicity. Option D is incorrect because avoiding caffeinated beverages is not a priority teaching point for clients taking lithium.

2. A client who has a positive stool culture for Clostridium difficile should be placed in which type of room for infection control purposes?

• A. Wear a face shield prior to entering the room.
• B. Place the client in a private room.
• C. Place the client in a negative pressure room.
• D. Use an alcohol-based hand rub following client care.

Correct answer: B

Rationale: Placing the client in a private room is the appropriate infection control measure for C. difficile to prevent the spread of infection. While wearing a face shield may be necessary for procedures that generate splashes or sprays, it is not the primary precaution for C. difficile. Negative pressure rooms are typically used for airborne infections, not for C. difficile. Using an alcohol-based hand rub is important for hand hygiene but is not specific to managing C. difficile infection.

3. A nurse is caring for a newborn who is 1-day-old and receiving phototherapy for jaundice. Which of the following actions should the nurse take?

• A. Feed the infant 30 ml (1 oz) of glucose water every 2 hours.
• B. Keep the infant's head covered with a cap.
• C. Ensure that the newborn wears a diaper.
• D. Apply lotion to the newborn every 4 hours.

Correct answer: C

Rationale: The correct action for the nurse to take is to ensure that the newborn wears a diaper. This is important to prevent skin irritation during phototherapy. Choice A is incorrect as newborns should be breastfed or formula-fed, not given glucose water. Choice B is unnecessary and may interfere with the effectiveness of phototherapy. Choice D is inappropriate as lotions can interfere with the phototherapy and increase the risk of skin damage.

4. A client with heart failure is being assessed by a nurse. Which of the following findings indicates the client is experiencing fluid overload?

• A. Dry, hacking cough
• B. Bounding peripheral pulses
• C. Decreased urinary output
• D. Weight loss of 1 kg in 24 hours

Correct answer: C

Rationale: In clients with heart failure, decreased urinary output is a classic sign of fluid overload. The kidneys try to compensate for the increased volume by reducing urine output, leading to fluid retention. A dry, hacking cough (choice A) is more indicative of heart failure complications like pulmonary edema. Bounding peripheral pulses (choice B) are a sign of increased volume, but not specifically fluid overload. Weight loss of 1 kg in 24 hours (choice D) is not indicative of fluid overload but rather rapid fluid loss.

5. A nurse is calculating a client's expected date of delivery. The client's last menstrual period began on April 12. Using Nagele's rule, what date should the nurse determine to be the client's expected delivery date?

• A. January 19
• B. 325
• C. 105
• D. 112

Correct answer: A

Rationale: Nagele's rule is a method used to calculate the expected delivery date by subtracting 3 months from the first day of the last menstrual period and adding 7 days. In this case, April 12 minus 3 months is January 12, plus 7 days gives January 19. Therefore, the correct answer is A. Choices B, C, and D do not align with the application of Nagele's rule and are incorrect.

Similar Questions