Nursing Elites

1. A nurse is teaching a client about the use of clopidogrel. Which of the following should be included?

• A. It is an anticoagulant
• B. Monitor for signs of bleeding
• C. It can be stopped abruptly
• D. Avoid foods rich in vitamin K

Correct answer: B

Rationale: The correct answer is B: 'Monitor for signs of bleeding.' Clopidogrel is an antiplatelet medication, not an anticoagulant. Clients taking clopidogrel should be monitored for signs of bleeding due to its antiplatelet effects. Choice A is incorrect because clopidogrel is not an anticoagulant. Choice C is incorrect as clopidogrel should not be stopped abruptly but as directed by a healthcare provider. Choice D is irrelevant since foods rich in vitamin K are more of a concern with anticoagulant medications like warfarin, not antiplatelet medications like clopidogrel.

2. Which of the following interventions is most appropriate for a client with hyperemesis gravidarum?

• A. Encourage high-calorie meals
• B. Administer intravenous fluids
• C. Provide frequent small meals
• D. Limit fluid intake

Correct answer: B

Rationale: The correct answer is B: Administer intravenous fluids. Hyperemesis gravidarum is severe, persistent nausea and vomiting during pregnancy that can lead to dehydration and electrolyte imbalances. The priority intervention is to administer intravenous fluids to maintain hydration. Encouraging high-calorie meals (Choice A) may exacerbate symptoms due to increased gastric stimulation. Providing frequent small meals (Choice C) may not be effective in severe cases where continuous vomiting occurs. Limiting fluid intake (Choice D) is contraindicated in hyperemesis gravidarum as dehydration is a significant concern.

3. A client with schizophrenia is experiencing auditory hallucinations. Which of the following actions should the nurse take first?

• A. Encourage the client to listen to music
• B. Ask the client what the voices are saying
• C. Provide the client with a distraction
• D. Administer an antipsychotic medication

Correct answer: B

Rationale: Asking the client what the voices are saying is the priority action as it helps assess the content of the hallucinations. This assessment is crucial to determine if the client is at risk of harm to themselves or others. Encouraging the client to listen to music or providing a distraction may not address the underlying issues related to the hallucinations. Administering antipsychotic medication, although important, should come after a thorough assessment of the hallucinations to ensure the right medication and dosage are provided.

4. A client with a permanent spinal cord injury is scheduled for discharge. Which of the following client statements indicates that the client is coping effectively?

• A. “I would like to play wheelchair basketball. When I get stronger, I think I’ll look for a league.”
• B. “I’m glad I’ll only be in this wheelchair temporarily. I can’t wait to get back to running.”
• C. “I’m so upset that this happened to me. What did I do to deserve this, and why am I not getting better?”
• D. “I feel like I’ll never be able to do anything that I want to again. All I am is a burden to my family.”

Correct answer: A

Rationale: Choice A is the correct answer. This statement demonstrates effective coping as the client is showing acceptance of their disability and planning for the future with realistic goals. Choice B reflects denial of the permanent disability by stating that they will only be in a wheelchair temporarily. Choice C shows distress and a lack of acceptance by questioning why the injury happened and why they are not improving. Choice D indicates feelings of hopelessness and being a burden, which are not signs of effective coping.

5. A nurse in an acute care facility is caring for a client who is postop following abdominal surgery. Which of the following behaviors should the nurse identify as increasing the client's risk for constipation?

• A. Regular fluid intake
• B. Urge suppression
• C. Increased physical activity
• D. Adequate dietary fiber

Correct answer: B

Rationale: Urge suppression can lead to constipation by delaying bowel movements and causing fecal impaction, especially in postoperative patients. Regular fluid intake (choice A) is important to prevent constipation by maintaining hydration and aiding in bowel movements. Increased physical activity (choice C) helps stimulate bowel function and prevent constipation. Adequate dietary fiber (choice D) is essential for promoting healthy bowel movements and preventing constipation. However, urge suppression (choice B) is the behavior that directly contributes to constipation in this scenario.

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