Nursing Elites

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

Correct answer: D

Rationale: The correct answer is D. New onset of tachypnea indicates a potential respiratory complication that requires immediate attention. Assessing the client with a hip fracture and tachypnea first is crucial to address the respiratory issue and prevent further deterioration. Choices A, B, and C do not present immediate life-threatening complications that require urgent assessment compared to a new onset of tachypnea.

2. A nurse is providing discharge instructions to a client who has a new prescription for haloperidol. Which of the following adverse effects should the nurse instruct the client to report to the provider?

• A. Weight gain.
• B. Dry mouth.
• C. Sedation.
• D. Shuffling gait.

Correct answer: D

Rationale: The correct answer is D: Shuffling gait. A shuffling gait can indicate extrapyramidal symptoms, a potentially serious side effect of haloperidol. Extrapyramidal symptoms include movement disorders such as dystonia, akathisia, parkinsonism, and tardive dyskinesia. Reporting this symptom promptly is crucial to prevent further complications. Choices A, B, and C are common side effects of haloperidol but are not as urgent or indicative of serious complications compared to a shuffling gait.

3. When caring for a client experiencing delirium, which of the following is essential?

• A. Controlling behavioral symptoms with low-dose psychotropics
• B. Identifying the underlying causative condition or illness
• C. Manipulating the environment to increase orientation
• D. Decreasing or discontinuing all previously prescribed medications

Correct answer: B

Rationale: When caring for a client experiencing delirium, it is essential to identify the underlying causative condition or illness. Delirium can be caused by various factors such as infections, medication side effects, dehydration, or underlying health conditions. By identifying the root cause, appropriate treatment can be provided. Controlling behavioral symptoms with low-dose psychotropics (Choice A) may be considered in some cases but is not the primary essential step. Manipulating the environment to increase orientation (Choice C) can help manage symptoms but does not address the underlying cause. Decreasing or discontinuing all previously prescribed medications (Choice D) should only be done under medical supervision, as some medications may be necessary for the client's well-being.

4. A client is to start taking furosemide and is being taught about dietary modifications by a nurse. Which of the following foods should the nurse recommend to the client?

• A. Cabbage
• B. Bananas
• C. Carrots
• D. Potatoes

Correct answer: B

Rationale: The correct answer is B: Bananas. Bananas are high in potassium, which helps counter the potassium-depleting effects of furosemide. Furosemide is a loop diuretic that can lead to potassium loss, so including potassium-rich foods like bananas in the diet can help maintain a healthy potassium level. Choices A, C, and D do not specifically address the potassium needs associated with furosemide therapy and are not the most appropriate recommendations in this context.

5. A client with diabetes is being discharged. What is the most important teaching point?

• A. Monitor blood sugar levels once in the morning
• B. Administer insulin before meals as prescribed
• C. Take medication only when feeling unwell
• D. Monitor glucose levels weekly

Correct answer: B

Rationale: The most important teaching point for a client with diabetes being discharged is to administer insulin before meals as prescribed. This is crucial for managing blood sugar levels effectively and preventing complications. Monitoring blood sugar levels once in the morning (Choice A) is not sufficient for proper diabetes management, as levels can fluctuate throughout the day. Taking medication only when feeling unwell (Choice C) is not recommended as diabetes treatment is based on a regular schedule. Monitoring glucose levels weekly (Choice D) is not frequent enough to provide the necessary information for managing diabetes on a day-to-day basis.

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