Nursing Elites

1. How should a healthcare professional monitor a patient for infection post-surgery?

• A. Monitor the surgical site
• B. Monitor for fever
• C. Check blood pressure
• D. Check for redness

Correct answer: A

Rationale: Monitoring the surgical site is crucial to identify early signs of infection post-surgery. Redness, swelling, warmth, or discharge at the surgical site can indicate an infection. While monitoring for fever (choice B) is important as fever can also be a sign of infection, it may not always present immediately post-surgery. Checking blood pressure (choice C) is essential for other purposes but not specifically for monitoring infection post-surgery. Checking for redness (choice D) is limited as redness alone may not always indicate an infection, so it is not as comprehensive as monitoring the surgical site.

2. A nurse is providing teaching to a client who has a new prescription for nitroglycerin transdermal patches. Which of the following instructions should the nurse include?

• A. Apply the patch to your upper arm.
• B. You should remove the patch before showering.
• C. Rotate the patch site each time you apply it.
• D. Apply the patch to your lower abdomen.

Correct answer: C

Rationale: The correct answer is to instruct the client to rotate the patch site each time they apply it. This practice helps prevent skin irritation and ensures the effectiveness of nitroglycerin transdermal patches. Applying the patch to the same site each time can lead to skin irritation and decreased patch efficacy. Choices A, B, and D are incorrect because applying the patch to the upper arm, removing it before showering, and placing it on the lower abdomen do not promote proper rotation of patch sites, which is essential for optimal outcomes.

3. A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets and has a respiratory rate of 10/min. After securing the client's airway and initiating an IV, which of the following actions should the nurse do next?

• A. Monitor the client's IV site for thrombophlebitis
• B. Administer flumazenil to the client
• C. Evaluate the client for further suicidal behavior
• D. Initiate seizure precautions for the client

Correct answer: B

Rationale: Administering flumazenil is the priority to reverse the effects of diazepam overdose. Monitoring the IV site for thrombophlebitis (choice A) is important but not the next immediate action. Evaluating the client for further suicidal behavior (choice C) is important but not the priority at this moment. Initiating seizure precautions (choice D) is not the priority action in this scenario.

4. A client with schizophrenia is beginning therapy with clozapine. Which statement indicates a need for further teaching?

• A. I will need to have my blood work checked regularly while taking clozapine.
• B. I understand that clozapine may cause me to gain weight.
• C. I should report any signs of a fever while taking clozapine.
• D. I should discontinue clozapine once my symptoms improve.

Correct answer: D

Rationale: The correct answer is D because clients should continue taking clozapine even if their symptoms improve. Abruptly discontinuing the medication can lead to relapse. Choices A, B, and C are all correct statements regarding clozapine therapy. Regular blood work monitoring is necessary due to potential side effects, weight gain is a common side effect of clozapine, and reporting signs of fever is important as it can indicate a serious side effect of clozapine.

5. What is the best way to monitor fluid balance in a patient receiving diuretics?

• A. Monitor daily weight
• B. Monitor intake and output
• C. Monitor blood pressure
• D. Check for edema

Correct answer: A

Rationale: Corrected Rationale: Daily weight monitoring is the most accurate way to assess fluid balance in patients receiving diuretics. Monitoring daily weight allows healthcare providers to track changes in fluid status more precisely. While monitoring intake and output (choice B) is essential, it may not provide a comprehensive picture of overall fluid balance. Monitoring blood pressure (choice C) is important but may not directly reflect fluid balance. Checking for edema (choice D) is useful but may not be as sensitive as daily weight monitoring in assessing fluid balance.

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