Nursing Elites

1. The client is being discharged and has been prescribed furosemide (Lasix). Which statement by the client indicates an understanding of the medication?

• A. I will take this medication on an empty stomach for optimal absorption.
• B. I will weigh myself daily and report any significant weight loss.
• C. I will include potassium-rich foods in my diet while taking this medication.
• D. I will take this medication in the morning to prevent nocturia.

Correct answer: B

Rationale: The correct answer is B. Weighing daily and reporting significant weight loss is crucial when taking furosemide to monitor for potential fluid and electrolyte imbalances. Choice A is incorrect because furosemide is typically taken on an empty stomach for optimal absorption. Choice C is incorrect as furosemide can lead to potassium loss, so potassium-rich foods should be consumed. Choice D is incorrect because furosemide is usually taken earlier in the day to prevent nocturia, not at bedtime.

2. A client is experiencing dehydration, and the nurse is planning care. Which of the following actions should the nurse include?

• A. Administer antihypertensives as prescribed.
• B. Check the client’s weight daily.
• C. Notify the provider if the urine output is less than 30 mL/hr.
• D. Encourage the client to ambulate independently four times a day.

Correct answer: B

Rationale: Checking the client's weight daily is essential for monitoring fluid status in dehydration. Administering antihypertensives, notifying the provider of insufficient urine output, and encouraging ambulation are not primary interventions for managing dehydration. Administering antihypertensives may affect blood pressure, but it is not a direct intervention for dehydration. Notifying the provider of a urine output less than 30 mL/hr indicates oliguria, which is a sign of reduced kidney function rather than dehydration. Encouraging ambulation is a general nursing intervention and does not directly address the fluid imbalance associated with dehydration.

3. While caring for a client who begins to experience a generalized seizure while standing in her room, which of the following actions should the nurse take?

• A. Place a pad under the client’s head
• B. Hold the client’s limbs tightly to prevent injury
• C. Lift the client into bed with the help of other staff members
• D. Insert a bite block into the client’s mouth

Correct answer: A

Rationale: During a seizure, the priority is to protect the client's head and ensure their safety. The nurse should guide the client to the ground if possible and place a soft pad or a folded cloth under the head to prevent injury. Restraining the client's limbs can result in injury and should be avoided. Lifting the client can also lead to injuries during a seizure. Inserting a bite block is contraindicated as it can cause damage to the teeth, oral tissues, and obstruct the airway. Therefore, the correct action is to place a pad under the client's head to protect them during the seizure.

4. UAP has lowered the head of the bed to change the linens for a client who is bedridden. Which observation...most immediate intervention by the nurse?

• A. A feeding is infusing at 40 mL/hr through an enteral feeding tube.
• B. The urine meter attached to the urinary drainage bag is completely full.
• C. There is a large dependent loop in the client's urinary drainage tubing.
• D. Purulent drainage is present around the insertion site of the feeding tube.

Correct answer: D

Rationale: The correct answer is D. Purulent drainage around the insertion site of the feeding tube indicates an infection, which requires immediate attention. This may be a sign of a serious complication that needs prompt nursing intervention to prevent further complications or deterioration in the client's condition. Choices A, B, and C do not indicate an immediate threat to the client's health. While option A highlights the infusion rate of the feeding, it does not pose an immediate risk compared to the presence of purulent drainage indicating infection.

5. A patient has scaling of the scalp. Which term will the nurse use to report this finding to the oncoming staff?

• A. Dandruff
• B. Alopecia
• C. Pediculosis
• D. Xerostomia

Correct answer: A

Rationale: The correct term the nurse will use to report scaling of the scalp is 'Dandruff.' Dandruff is characterized by scaling of the scalp that is often accompanied by itching. Choice B, 'Alopecia,' refers to hair loss, not scaling. Choice C, 'Pediculosis,' is the infestation of lice, not scaling. Choice D, 'Xerostomia,' pertains to dry mouth, which is unrelated to the described symptom of scaling of the scalp.

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