Nursing Elites

1. The nurse is caring for a client with increased intracranial pressure (ICP). Which position should the nurse avoid?

• A. Keeping the head of the bed elevated at 30 degrees
• B. Positioning the client in the prone position
• C. Placing the client in a lateral recumbent position
• D. Elevating the client's legs

Correct answer: B

Rationale: The correct answer is B: Positioning the client in the prone position. Placing the client in the prone position should be avoided in a client with increased intracranial pressure (ICP) as it can further raise ICP. The prone position can hinder venous return and increase pressure within the cranial vault, potentially worsening the client's condition. Keeping the head of the bed elevated at 30 degrees helps promote venous drainage and reduce ICP. Placing the client in a lateral recumbent position can also assist in reducing ICP by optimizing cerebral perfusion. Elevating the client's legs can help improve venous return and maintain adequate cerebral blood flow, making it a suitable positioning intervention for managing increased ICP.

2. The nurse is assessing a client with congestive heart failure who is receiving furosemide (Lasix). Which laboratory value should the nurse monitor closely?

• A. Sodium level
• B. Potassium level
• C. Calcium level
• D. Chloride level

Correct answer: B

Rationale: The correct answer is B: Potassium level. Furosemide is a loop diuretic that can cause potassium loss, leading to hypokalemia. Monitoring the potassium level is crucial to prevent complications such as cardiac arrhythmias. Sodium level (choice A) is not typically affected by furosemide. Calcium level (choice C) and chloride level (choice D) are also not the primary focus of monitoring when a client is on furosemide for heart failure.

3. The nurse is assessing a client who has been diagnosed with chronic obstructive pulmonary disease (COPD). Which clinical finding is characteristic of this condition?

• A. Pursed-lip breathing
• B. Hyperresonance on percussion
• C. Bradycardia
• D. High-pitched inspiratory crackles

Correct answer: A

Rationale: Pursed-lip breathing is a characteristic finding in clients with COPD. It helps keep the airways open during exhalation, acting as a compensatory mechanism to prevent airway collapse, which is common in COPD. Hyperresonance on percussion is typically found in conditions like emphysema, which is a component of COPD but not characteristic of the overall disease. Bradycardia is not typical in COPD; instead, clients often exhibit tachycardia due to chronic hypoxemia. High-pitched inspiratory crackles are more commonly associated with conditions like pneumonia, not COPD.

4. The client with heart failure is prescribed furosemide (Lasix). What should the nurse include in the teaching plan?

• A. Increase potassium-rich foods in the diet
• B. Avoid foods high in sodium
• C. Monitor fluid intake and adjust as needed
• D. Take the medication in the morning

Correct answer: A

Rationale: The correct answer is to instruct the client to increase potassium-rich foods in the diet. Furosemide is a loop diuretic that can cause potassium loss as a side effect. By increasing potassium-rich foods, the client can help prevent hypokalemia, a potential complication of furosemide therapy. Choice B is incorrect because while limiting sodium intake is generally advisable for heart failure, it is not directly related to furosemide use. Choice C is incorrect because fluid intake should be monitored and adjusted based on the individual's condition, but setting a specific limit of 1 liter per day is not a standard recommendation. Choice D is incorrect because furosemide is usually taken in the morning to prevent disturbances in sleep due to increased urination during the night.

5. What is the most important information for the nurse to provide to a client with a diagnosis of major depressive disorder who is started on a selective serotonin reuptake inhibitor (SSRI)?

• A. Take the medication with food
• B. Avoid foods high in tyramine
• C. Report any thoughts of self-harm immediately
• D. Expect to see improvement within 24 hours

Correct answer: C

Rationale: The correct answer is C: 'Report any thoughts of self-harm immediately.' When starting an SSRI, clients should be informed to report any thoughts of self-harm promptly. SSRIs can initially increase suicidal ideation, especially in the early stages of treatment. This information is crucial for the client's safety and well-being. Choices A, B, and D are incorrect because taking the medication with food, avoiding foods high in tyramine, and expecting immediate improvement within 24 hours are not the most critical pieces of information for a client starting on an SSRI.

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