Nursing Elites

1. A nurse is providing teaching to a client who has a new prescription for prednisone. Which of the following instructions should the nurse include?

• A. Take this medication on an empty stomach.
• B. Take this medication in the evening.
• C. You should avoid taking this medication with dairy products.
• D. You should monitor for signs of infection while taking this medication.

Correct answer: D

Rationale: The correct answer is D: "You should monitor for signs of infection while taking this medication." When a client is prescribed prednisone, it is essential to monitor for signs of infection due to the immunosuppressive effects of corticosteroids. Choices A, B, and C are incorrect because prednisone does not need to be taken on an empty stomach, at a specific time of day, or avoided with dairy products.

2. A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?

• A. A client who has sinus arrhythmia and is receiving monitoring.
• B. A client who has a hip fracture and a new onset of tachypnea.
• C. A client who has epidural analgesia and weakness in the lower extremities.
• D. A client who has diabetes and a hemoglobin A1C of 6.8%.

Correct answer: B

Rationale: The correct answer is B because a new onset of tachypnea can indicate a respiratory complication, which requires immediate assessment. Sinus arrhythmia, epidural analgesia with weakness, and a hemoglobin A1C level of 6.8% in a client with diabetes do not pose immediate life-threatening concerns that require urgent assessment compared to the potential respiratory issues associated with tachypnea.

3. A client is postoperative following a total knee arthroplasty. Which of the following instructions should the nurse include in the discharge teaching?

• A. Cross your legs when sitting to prevent discomfort.
• B. Perform range-of-motion exercises every 4 hours.
• C. Wear compression stockings daily.
• D. Apply heat to the incision site daily.

Correct answer: C

Rationale: The correct answer is C: 'Wear compression stockings daily.' Wearing compression stockings is essential after knee surgery to prevent venous stasis and reduce the risk of blood clots. Choice A is incorrect as crossing legs when sitting can increase the risk of blood clots. Choice B is incorrect because performing range-of-motion exercises every 4 hours may not be suitable for all clients post total knee arthroplasty. Choice D is incorrect as applying heat to the incision site can increase the risk of infection.

4. A nurse is caring for a client who is receiving radiation therapy. Which of the following side effects should the nurse monitor for?

• A. Fatigue
• B. Hair loss
• C. Nausea
• D. Dry mouth

Correct answer: D

Rationale: The correct answer is D, dry mouth. Dry mouth is a common side effect of radiation therapy due to damage to the salivary glands. It is essential for the nurse to monitor for this condition as it can lead to oral health issues and discomfort. Fatigue (choice A) is a common side effect of radiation therapy, but in this case, dry mouth is a more specific side effect to monitor for. Hair loss (choice B) is more commonly associated with chemotherapy rather than radiation therapy. Nausea (choice C) is also a common side effect of radiation therapy, but dry mouth is a more direct effect of the treatment that the nurse should focus on monitoring.

5. A nurse is assessing a client who has a chest tube and notes continuous bubbling in the water seal chamber. Which of the following actions should the nurse take?

• A. Continue to monitor the client.
• B. Clamp the chest tube.
• C. Replace the drainage system.
• D. Apply a dressing over the insertion site.

Correct answer: D

Rationale: The correct action for the nurse to take when continuous bubbling is noted in the water seal chamber of a chest tube is to apply a dressing over the insertion site. Continuous bubbling indicates an air leak, and applying a dressing helps manage this issue by providing a seal. Clamping the chest tube or replacing the drainage system is not appropriate in this situation as it can lead to complications such as tension pneumothorax or inadequate drainage of the pleural space.

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