Nursing Elites

1. The home care nurse visits a client who has cancer. The client reports having a good appetite but experiencing nausea when smelling food cooking. Which action should the nurse implement?

• A. Encourage family members to cook meals outdoors and bring the cooked food inside
• B. Provide anti-nausea medication prior to meals
• C. Suggest drinking cold water with meals to reduce nausea
• D. Recommend smaller, frequent meals

Correct answer: A

Rationale: In some cases, the smell of food cooking can trigger nausea in cancer patients. Cooking food outside reduces the intensity of odors that could trigger nausea, helping the client maintain adequate nutrition. Providing anti-nausea medication (Choice B) may not address the root cause of the nausea triggered by the smell of cooking food. Suggesting cold water (Choice C) or smaller, frequent meals (Choice D) may not directly address the issue of cooking odors triggering nausea, which is specific to this client's situation.

2. A client with a urinary tract infection is prescribed ciprofloxacin. What is the nurse's priority teaching?

• A. Take the medication with a full glass of water.
• B. Avoid direct sunlight while taking the medication.
• C. Take the medication with meals to prevent nausea.
• D. Discontinue the medication if you experience dizziness.

Correct answer: A

Rationale: The correct answer is A: 'Take the medication with a full glass of water.' It is crucial for the nurse to teach the client to take ciprofloxacin with a full glass of water to prevent crystalluria, a potential side effect of the medication. Choice B is incorrect because ciprofloxacin does not require avoiding direct sunlight. Choice C is incorrect as taking the medication with meals is not necessary to prevent nausea. Choice D is incorrect as dizziness is not a common reason to discontinue ciprofloxacin.

3. A client with heart failure is prescribed digoxin. What assessment finding should the nurse report immediately?

• A. Bradycardia of 50 beats per minute.
• B. Heart rate of 110 beats per minute.
• C. Respiratory rate of 16 breaths per minute.
• D. Blood pressure of 130/80 mmHg.

Correct answer: A

Rationale: The correct answer is A: Bradycardia of 50 beats per minute. Bradycardia is a critical assessment finding in a client prescribed with digoxin, as it can indicate digoxin toxicity. Bradycardia is a known side effect of digoxin, and if left unaddressed, it can lead to serious complications such as arrhythmias or cardiac arrest. Both choices B, heart rate of 110 beats per minute, and C, respiratory rate of 16 breaths per minute, fall within normal ranges and do not raise immediate concerns. Choice D, blood pressure of 130/80 mmHg, is also within normal limits and does not indicate digoxin toxicity. Therefore, the nurse should report bradycardia promptly to prevent further complications.

4. A client with acute pancreatitis is receiving intravenous fluids and pain medication. What is the priority assessment for this client?

• A. Monitor bowel sounds
• B. Measure urine output
• C. Assess for abdominal tenderness
• D. Monitor blood glucose levels

Correct answer: D

Rationale: The correct answer is D: Monitor blood glucose levels. Clients with acute pancreatitis are prone to hyperglycemia due to impaired insulin production. Monitoring blood glucose levels is crucial to prevent complications like diabetic ketoacidosis. While assessing bowel sounds, urine output, and abdominal tenderness are important in the overall care of a client with acute pancreatitis, monitoring blood glucose levels takes priority to address the immediate risk of hyperglycemia.

5. Before administering digoxin to a client with heart failure, what is the most important assessment for the nurse to perform?

• A. Check the client's blood pressure
• B. Monitor the client's heart rate
• C. Assess the client's respiratory rate
• D. Review the client's potassium level

Correct answer: B

Rationale: The correct answer is to monitor the client's heart rate. Digoxin slows the heart rate, so it is crucial to assess the heart rate before administering the medication. If the heart rate is below 60 beats per minute, the dose should be held, and the healthcare provider should be notified. Checking the blood pressure (Choice A) is important but not as crucial as monitoring the heart rate in this case. Assessing the respiratory rate (Choice C) is not directly related to the action of digoxin. Reviewing the client's potassium level (Choice D) is important for clients taking digoxin due to the risk of hypokalemia, but assessing the heart rate takes priority.

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