Nursing Elites

1. A client with a new diagnosis of heart failure is prescribed furosemide. Which of the following instructions should the nurse include?

• A. Take the medication in the morning.
• B. Increase intake of potassium-rich foods.
• C. Report a decrease in urine output.
• D. Expect swelling in the lower extremities.

Correct answer: B

Rationale: The correct answer is to instruct the client to increase their intake of potassium-rich foods. Furosemide, a loop diuretic, can lead to potassium loss, which may cause hypokalemia. Increasing potassium intake can help prevent this electrolyte imbalance. Choice A is incorrect because furosemide is usually taken in the morning to prevent sleep disturbances due to increased urination. Choice C is incorrect because a decrease in urine output could indicate a problem and should be reported immediately. Choice D is incorrect because furosemide is used to reduce swelling in the body, including the lower extremities, so expecting swelling is not appropriate.

2. A nurse is providing discharge teaching to a client who has a prescription for home oxygen. Which information should the nurse teach?

• A. Use a humidifier with the oxygen
• B. Wear cotton socks when the oxygen is in use
• C. Avoid all types of smoking materials
• D. Use a nasal cannula during meals

Correct answer: B

Rationale: The correct answer is B: 'Wear cotton socks when the oxygen is in use.' This information is important as wearing cotton socks helps prevent static electricity, which can pose a fire risk when oxygen is in use. Choice A is incorrect as using a humidifier with oxygen is not necessary for all clients and may not be part of standard discharge teaching. Choice C is incorrect as it is a common safety measure to avoid all types of smoking materials when using oxygen. Choice D is incorrect as using a nasal cannula during meals is not specifically related to the safety concerns associated with home oxygen use.

3. A nurse on the medical-surgical unit is receiving reports on four clients. Which of the following clients should the nurse assess first?

• A. A client who is receiving warfarin and has an INR of 3.3
• B. A client who has acute kidney injury, creatinine 4 mg/dL, and BUN 52 mg/dL
• C. A client who had an NG tube inserted 6 hours ago and has abdominal distention
• D. A client who is 4 hours postoperative following a thyroidectomy and reports fullness in the throat

Correct answer: D

Rationale: The client who is 4 hours postoperative following a thyroidectomy and reports fullness in the throat should be assessed first. This client may be experiencing airway obstruction due to hematoma or swelling, making it a priority. Options A, B, and C have concerning findings as well, but airway compromise takes precedence over other issues.

4. A nurse is caring for a client who repeatedly refuses meals. The nurse overhears an assistive personnel telling the client, “If you don’t eat, I’ll put restraints on your wrists and feed you.” The nurse should intervene and explain to the AP that this statement constitutes which of the following torts?

• A. Assault
• B. Battery
• C. Malpractice
• D. Negligence

Correct answer: A

Rationale: The correct answer is A: Assault. Assault is the act of threatening a client with harm, such as the threat of using restraints to force-feed the client, even if no physical contact occurs. In this scenario, the statement made by the assistive personnel constitutes assault because it involves the threat of harm. Choice B, Battery, involves actual physical contact without the client's consent, which is not present in the scenario. Choice C, Malpractice, refers to professional negligence or misconduct, not a direct threat to the client. Choice D, Negligence, involves failure to provide reasonable care that results in harm, which is not applicable in this context.

5. A nurse is caring for a client prescribed hydromorphone for severe pain. The client's respiratory rate has decreased from 16 breaths per minute to 6. Which of the following medications should the nurse prepare to administer?

• A. Naloxone
• B. Flumazenil
• C. Activated charcoal
• D. Aluminum hydroxide

Correct answer: A

Rationale: Naloxone is the correct answer. Naloxone is the antidote for opioid overdose, including hydromorphone. Opioids can cause respiratory depression, and a significant decrease in respiratory rate from 16 to 6 breaths per minute indicates respiratory compromise. Naloxone should be administered promptly to reverse the effects of the opioid and restore normal respiratory function. Flumazenil (Choice B) is used to reverse the effects of benzodiazepines, not opioids. Activated charcoal (Choice C) is used for gastrointestinal decontamination in cases of overdose with certain substances, but it is not the appropriate intervention for opioid-induced respiratory depression. Aluminum hydroxide (Choice D) is an antacid and has no role in managing opioid overdose or respiratory depression.

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