Nursing Elites

1. A nurse receives a change-of-shift report. Which of the following clients should the nurse attend to first?

• A. A client who reports tingling in the fingers following a thyroidectomy
• B. A client who has dark, foul-smelling urine with a urine output of 320 mL in the last 8 hr
• C. A client who is in a long leg cast and reports cool feet bilaterally
• D. A client who has a productive cough and an oral temperature of 36°C (96.8°F)

Correct answer: C

Rationale: The correct answer is C. Cool feet bilaterally in a client with a long leg cast may indicate compromised circulation, which is a medical emergency that requires immediate intervention. Choices A, B, and D do not present immediate life-threatening conditions. Tingling in the fingers following a thyroidectomy may indicate hypocalcemia but does not require immediate attention. Dark, foul-smelling urine with decreased urine output indicates a possible urinary tract infection or dehydration but can be addressed after attending to the client with compromised circulation. A productive cough and a normal oral temperature do not suggest an urgent condition compared to compromised circulation in a client with a long leg cast.

2. A nurse is caring for a client prescribed ferrous sulfate for the treatment of anemia. Which of the following instructions should be included in client teaching about this medication?

• A. Take the medication on an empty stomach
• B. Notify your provider if your stool becomes dark green
• C. Decrease dietary fiber intake while taking this medication
• D. Take prescribed antacids at the same time as this medication

Correct answer: A

Rationale: The correct instruction for a client prescribed ferrous sulfate for anemia is to take the medication on an empty stomach. This is because ferrous sulfate is best absorbed in an acidic environment, which is enhanced on an empty stomach. However, if the client experiences gastrointestinal side effects, they can take the medication with food. Choice B, notifying the provider if stool becomes dark green, is correct because dark or black stools are common with iron therapy and not a cause for concern. Choice C, decreasing dietary fiber intake, is incorrect as dietary fiber does not interfere with the absorption of ferrous sulfate. Choice D, taking prescribed antacids at the same time, is incorrect as antacids can decrease the absorption of ferrous sulfate.

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

• A. It can cause drowsiness
• B. It has no side effects
• C. It is a pain reliever
• D. It can be taken with food

Correct answer: A

Rationale: The correct answer is A: 'It can cause drowsiness.' Gabapentin is known to cause drowsiness, and clients should be warned about this side effect. Choice B is incorrect because gabapentin, like any medication, can have side effects. Choice C is incorrect because although gabapentin is used for pain management, it is not classified as a pain reliever. Choice D is incorrect because gabapentin should be taken as prescribed by the healthcare provider, and specific instructions regarding food intake should be provided based on individual needs.

4. A nurse is assessing a client who has anemia. Which of the following findings should the nurse expect?

• A. Bounding pulse
• B. Conjunctival pallor
• C. Elevated blood pressure
• D. Glossitis

Correct answer: B

Rationale: The correct answer is B: Conjunctival pallor. In anemia, there is a decrease in hemoglobin levels, leading to paleness of the conjunctiva. This is a common finding in individuals with anemia. Bounding pulse (choice A) is not typically associated with anemia but can be seen in conditions like hyperthyroidism. Elevated blood pressure (choice C) is not a common finding in anemia; instead, blood pressure may be low due to decreased oxygen-carrying capacity. Glossitis (choice D), or a swollen tongue, can be seen in certain types of anemia but is not as specific or common as conjunctival pallor.

5. A client has developed a pulmonary embolism. Which of the following interventions should the nurse implement first?

• A. Administer oxygen
• B. Prepare the client for a thoracentesis
• C. Elevate the client’s lower extremities
• D. Administer anticoagulant therapy

Correct answer: A

Rationale: Administering oxygen is the priority intervention for a client with a pulmonary embolism. Pulmonary embolism can lead to impaired gas exchange, causing hypoxemia. Administering oxygen helps to maintain adequate oxygenation levels. Thoracentesis is not indicated for a pulmonary embolism, as it is a procedure to remove fluid or air from the pleural space, not a treatment for embolism. Elevating the client's lower extremities is not a priority in the management of a pulmonary embolism. Administering anticoagulant therapy is important in the treatment of pulmonary embolism to prevent further clot formation, but it is not the first intervention. Oxygen administration takes precedence to address the immediate oxygenation needs of the client.

Similar Questions