Nursing Elites

1. A nurse overhears two assistive personnel (APs) discussing a client in a hospital cafeteria, using the client’s name and discussing details of the diagnosis. Which of the following actions should the nurse take first?

• A. Report the APs' behavior to the supervisor
• B. Complete an incident report regarding the APs' conversation
• C. Provide the APs with written documentation on confidentiality
• D. Tell the APs to discontinue their conversation

Correct answer: D

Rationale: The correct action for the nurse to take first is to tell the APs to discontinue their conversation. By stopping the conversation immediately, the nurse addresses the breach of client confidentiality on the spot. This action is crucial to protect the client's privacy and confidentiality. While further steps such as reporting the behavior or providing education on confidentiality may be necessary, the immediate priority is to stop the inappropriate discussion. Reporting the behavior to the supervisor or completing an incident report can come after the immediate issue is addressed. Providing written documentation on confidentiality may be helpful but is not the most urgent action needed in this situation.

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

• A. It should not be taken with nitrates
• B. Monitor for headaches
• C. It is a prescription medication
• D. It may have side effects

Correct answer: B

Rationale: The correct answer is to monitor for headaches when taking sildenafil. This medication can cause headaches and other side effects, so it is crucial to inform clients about these potential adverse reactions. Choice A is incorrect because sildenafil should not be taken with nitrates due to the risk of severe hypotension. Choice C is incorrect as sildenafil is a prescription medication, not an over-the-counter one. Choice D is incorrect because sildenafil, like any medication, can have side effects that should be discussed with the client.

3. A nurse is preparing to insert an indwelling urinary catheter into a female client. Which of the following actions should the nurse take?

• A. Inflate the balloon with 10 mL of sterile water prior to insertion
• B. Cleanse the client’s labia and meatus using a front-to-back motion
• C. Ask the client to bear down while inserting the catheter
• D. Inflate the catheter balloon after urine begins to flow

Correct answer: D

Rationale: The correct action for the nurse to take when inserting an indwelling urinary catheter into a female client is to inflate the catheter balloon after urine begins to flow. Inflating the balloon before urine starts flowing can lead to incorrect placement in the urethra, causing trauma. Cleansing the labia and meatus should be done before the insertion, but the crucial step of inflating the balloon should occur after the catheter is correctly placed. Asking the client to bear down is not necessary during catheter insertion.

4. A nurse is providing discharge teaching to a client who is starting to take carbidopa/levodopa to treat Parkinson’s disease. Which of the following instructions should the nurse include in the teaching?

• A. “This medication can cause your urine to turn a dark color.”
• B. “Expect immediate relief after taking this medication.”
• C. “Take the medication with a high-protein food.”
• D. “Skip a dose of the medication if you experience dizziness.”

Correct answer: A

Rationale: The correct instruction the nurse should provide is that the medication can cause the client's urine to turn a dark color, which is a harmless effect of carbidopa/levodopa. This is due to the metabolites of levodopa. Immediate relief is not expected after taking the medication because it may take weeks to months to achieve the full therapeutic effect. Taking the medication with a high-protein food is not recommended as protein can interfere with the absorption of levodopa. Skipping a dose of the medication if the client experiences dizziness is incorrect as dizziness may be a side effect of the medication, and doses should not be skipped without consulting a healthcare provider.

5. A nurse is preparing to administer IV furosemide. Which of the following should the nurse monitor for during the infusion?

• A. Increased urinary output
• B. Ototoxicity
• C. Hypokalemia
• D. Hypoglycemia

Correct answer: C

Rationale: The correct answer is C: Hypokalemia. Furosemide is a loop diuretic that works by increasing the excretion of water and electrolytes, particularly potassium. Therefore, the nurse should monitor for hypokalemia, as low potassium levels can lead to various complications such as cardiac dysrhythmias. Choice A, increased urinary output, is an expected effect of furosemide due to its diuretic action but is not a side effect needing monitoring. Ototoxicity (Choice B) is a potential adverse effect of other medications like aminoglycoside antibiotics, not furosemide. Hypoglycemia (Choice D) is not a common side effect associated with furosemide administration.

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