Nursing Elites

1. A client is prescribed albuterol. Which of the following instructions should the nurse include?

• A. Take this medication before meals.
• B. You might experience tremors while taking this medication.
• C. Limit your caffeine intake while taking this medication.
• D. Take this medication at bedtime.

Correct answer: B

Rationale: The correct answer is B. Albuterol can cause tremors as a common side effect. Instructing the client about this potential side effect is crucial for their awareness and preparedness. Choices A, C, and D are incorrect because taking albuterol before meals, limiting caffeine intake, or taking it at bedtime are not specific instructions related to managing the side effects of albuterol like tremors.

2. A nurse is caring for a client with deep vein thrombosis who is prescribed warfarin. Which of the following client statements indicates a need for further teaching?

• A. I will avoid vitamin K-rich foods.
• B. I will avoid using aspirin while on this medication.
• C. I will monitor my blood pressure regularly.
• D. I will increase my intake of leafy greens.

Correct answer: D

Rationale: The correct answer is D. Warfarin's effectiveness is reduced by high intake of vitamin K-rich foods, so increasing their intake would contradict the treatment plan. Choices A, B, and C are all appropriate statements for a client on warfarin therapy. Avoiding vitamin K-rich foods helps maintain the medication's effectiveness, avoiding aspirin reduces the risk of bleeding, and monitoring blood pressure is essential for overall health monitoring.

3. What is the most appropriate action when a patient is experiencing severe dehydration?

• A. Administer IV fluids
• B. Encourage oral fluids
• C. Monitor electrolytes
• D. Perform a neurological exam

Correct answer: A

Rationale: The most appropriate action when a patient is experiencing severe dehydration is to administer IV fluids. This intervention is crucial in rapidly correcting dehydration and restoring fluid balance. Encouraging oral fluids may not be sufficient in cases of severe dehydration where intravenous rehydration is needed. Monitoring electrolytes is important but administering fluids takes precedence in severe dehydration. Performing a neurological exam is not the primary intervention for severe dehydration.

4. A nurse is preparing to administer a rectal suppository to a client. What action should the nurse take?

• A. Encourage the client to hold their breath as long as possible.
• B. Insert the suppository just past the anal sphincter.
• C. Lubricate the suppository and insert it 1.5 cm (0.6 in) into the rectum.
• D. Place the client in a Sims' position before inserting the suppository.

Correct answer: D

Rationale: The correct action the nurse should take when administering a rectal suppository is to place the client in a Sims' position. This position helps facilitate the proper administration of the suppository by allowing better access to the rectum. Encouraging the client to hold their breath as long as possible (Choice A) is unnecessary and not related to the administration of a rectal suppository. Inserting the suppository just past the anal sphincter (Choice B) is incorrect as it may not reach the rectum where it needs to be placed. Lubricating the suppository and inserting it 1.5 cm into the rectum (Choice C) is incorrect as the suppository needs to be inserted deeper into the rectum for proper absorption.

5. A nurse in the PACU is caring for a client who reports nausea. Which of the following actions should the nurse take first?

• A. Turn the client on their side.
• B. Administer an analgesic.
• C. Administer antiemetic.
• D. Monitor the client's vital signs.

Correct answer: A

Rationale: The correct action the nurse should take first when a client reports nausea in the PACU is to turn the client on their side. This action helps prevent aspiration in a client with nausea, reducing the risk of choking or inhaling vomitus. Administering an analgesic (Choice B) is not the priority in this situation unless pain is the primary cause of nausea. While administering an antiemetic (Choice C) can help relieve nausea, it is not the initial action to prevent aspiration. Monitoring the client's vital signs (Choice D) is important but should come after ensuring the client's safety by turning them on their side.

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