Nursing Elites

1. The client is advised to take dexamethasone (Decadron) with food or milk. What is the physiological basis for this advice?

• A. Inhibits pepsin production
• B. Stimulates hydrochloric acid production
• C. Delays stomach emptying time
• D. Reduces hydrochloric acid production

Correct answer: B

Rationale: The correct answer is B: Stimulates hydrochloric acid production. Dexamethasone can stimulate the production of hydrochloric acid in the stomach, which may lead to irritation of the stomach lining. Taking dexamethasone with food or milk helps to neutralize or buffer the acid, reducing the risk of stomach irritation. Choice A is incorrect because dexamethasone does not inhibit pepsin production. Choice C is incorrect as dexamethasone does not slow stomach emptying time. Choice D is incorrect as dexamethasone does not reduce hydrochloric acid production.

2. A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process?

• A. Compare prescriptions with medications the client received during hospitalization.
• B. Only review the client’s current medications.
• C. Provide a list of medications without checking for interactions.
• D. Discuss the client’s medication history without verification.

Correct answer: A

Rationale: The correct answer is A: Compare prescriptions with medications the client received during hospitalization. This step is crucial in ensuring the accuracy of medication reconciliation. By comparing the current prescriptions with the medications administered during the hospital stay, the nurse can identify any discrepancies, omissions, or duplications in the medications. This comprehensive comparison helps prevent medication errors and ensures that the client's home medications align with the treatment received in the hospital. Choice B is incorrect because solely reviewing the client's current medications may overlook important changes or additions made during the hospitalization. Choice C is incorrect as providing a list of medications without checking for interactions can lead to potential adverse effects or drug interactions. Choice D is incorrect as discussing the client's medication history without verification may not provide an accurate representation of the medications the client actually received during the hospital stay.

3. The healthcare provider is caring for a client with dehydration. Which assessment finding indicates that the client is responding to treatment?

• A. Dry mucous membranes
• B. Increased urine output
• C. Decreased heart rate
• D. Elevated blood pressure

Correct answer: B

Rationale: Increased urine output is the correct assessment finding that indicates the client is responding to treatment for dehydration. When a client is dehydrated, their urine output tends to decrease as the body tries to conserve fluids. Therefore, an increase in urine output suggests that the client's hydration status is improving. Dry mucous membranes (Choice A) are a sign of dehydration and would not indicate a positive response to treatment. Decreased heart rate (Choice C) and elevated blood pressure (Choice D) are not specific indicators of hydration status in a client with dehydration.

4. When obtaining a urine specimen for a culture and sensitivity from an indwelling catheter, the nurse should:

• A. Cleanse the entry port prior to withdrawing urine.
• B. Use a sterile syringe to collect urine from the collection bag.
• C. Obtain the specimen from the drainage tubing.
• D. Replace the catheter before obtaining the specimen.

Correct answer: A

Rationale: The correct procedure when obtaining a urine specimen from an indwelling catheter for culture and sensitivity is to cleanse the entry port before withdrawing urine. This step helps reduce the risk of contamination and ensures the accuracy of the results. Option B is incorrect because using a sterile syringe to collect urine from the collection bag is not the recommended method for obtaining a catheter specimen. Option C is incorrect as obtaining the specimen from the drainage tubing is not the appropriate technique for collecting a urine sample from an indwelling catheter. Option D is incorrect because replacing the catheter before obtaining the specimen is not necessary and may introduce unnecessary complications.

5. A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor?

• A. Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back
• B. Pinch the skin on the back of the hand and observe for elasticity
• C. Assess the skin turgor on the abdomen by pinching the skin
• D. Check the skin turgor by pressing on the forearm and observing the rebound

Correct answer: A

Rationale: To assess skin turgor, the nurse should grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back. This method is preferred for older adults and in cases of significant fluid imbalance. Option B is incorrect as assessing skin turgor on the back of the hand is not the standard assessment site for skin turgor. Option C is incorrect as the abdomen is not the typical area for assessing skin turgor; the chest under the clavicle is a more accurate site. Option D is incorrect as pressing on the forearm is not the appropriate site for evaluating skin turgor; the chest under the clavicle is the recommended location for this assessment.

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