Nursing Elites

1. A client with heart failure and a new prescription for furosemide is receiving teaching from a nurse. Which of the following instructions should the nurse include?

• A. Avoid foods high in magnesium
• B. Take furosemide with food
• C. Eat foods that are rich in potassium
• D. Expect a decrease in blood pressure

Correct answer: C

Rationale: The correct instruction the nurse should include is to advise the client to eat foods that are rich in potassium. Furosemide is a loop diuretic that can cause the loss of potassium, leading to hypokalemia. Eating foods high in potassium can help prevent this electrolyte imbalance. Choice A is incorrect because furosemide does not directly interact with magnesium. Choice B is incorrect because furosemide is usually taken in the morning to prevent nighttime diuresis. Choice D is incorrect because furosemide is a diuretic that typically leads to a decrease in blood pressure rather than an increase.

2. A charge nurse is planning care for a group of patients on a med-surg unit. What task should the nurse delegate to an assistive personnel?

• A. Measure hourly urinary output for the postoperative patient.
• B. Administer medications to stable patients.
• C. Reinforce patient education.
• D. Initiate a care plan for a new patient.

Correct answer: A

Rationale: The correct answer is A because assistive personnel can be assigned to measure and document urinary output, a routine task within their scope of practice. Administering medications (choice B) requires a higher level of training and should be done by licensed nurses. Reinforcing patient education (choice C) involves providing information and ensuring patient understanding, which is typically done by licensed healthcare providers. Initiating a care plan (choice D) involves critical thinking and assessment skills, which are beyond the scope of practice for assistive personnel.

3. A healthcare provider is assessing a client with chronic obstructive pulmonary disease (COPD) receiving oxygen therapy. Which of the following findings indicates oxygen toxicity?

• A. Oxygen saturation 94%
• B. Decreased respiratory rate
• C. Wheezing
• D. Peripheral cyanosis

Correct answer: B

Rationale: The correct answer is B: Decreased respiratory rate. In clients with COPD, especially when receiving oxygen therapy, a decreased respiratory rate is indicative of oxygen toxicity. This occurs because their respiratory drive is often dependent on low oxygen levels. Oxygen saturation of 94% is within an acceptable range and does not necessarily indicate oxygen toxicity. Wheezing is more commonly associated with airway narrowing or constriction, while peripheral cyanosis is a sign of decreased oxygen levels in the peripheral tissues, not oxygen toxicity.

4. A nurse is caring for a newborn with hyperbilirubinemia. Which of the following interventions should be taken during phototherapy?

• A. Maintain an eye mask over the newborn's eyes
• B. Feed the newborn every hour
• C. Monitor the newborn's temperature
• D. Administer vitamin K

Correct answer: A

Rationale: During phototherapy for a newborn with hyperbilirubinemia, it is crucial to maintain an eye mask over the newborn's eyes. The purpose of the eye mask is to protect the infant's eyes from potential damage caused by the intense light used in phototherapy. While feeding the newborn frequently and monitoring temperature are essential aspects of newborn care, they are not specific to phototherapy. Administering vitamin K is important for newborns to prevent bleeding disorders but is not directly related to phototherapy for hyperbilirubinemia.

5. A healthcare provider is assessing a client who has severe dehydration. Which finding indicates effective treatment?

• A. Sunken anterior fontanel
• B. Tenting skin turgor
• C. Flat anterior fontanel
• D. Hyperpnea

Correct answer: C

Rationale: A flat anterior fontanel indicates effective treatment for dehydration in infants. Dehydration often causes sunken fontanels, so when the anterior fontanel becomes flat, it suggests that rehydration has occurred. Sunken anterior fontanel (Choice A) is a sign of dehydration, not effective treatment. Tenting skin turgor (Choice B) is also a sign of dehydration, indicating poor skin turgor. Hyperpnea (Choice D) is increased depth and rate of breathing and is not directly related to the hydration status of the client.

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