Nursing Elites

1. The nurse supervises care of a client in Buck’s traction. The nurse determines that care is appropriate if which of the following is observed? (Select all that apply)

• A. The nurse removes the foam boot three times per day to inspect the skin
• B. The staff turn the client to the unaffected side
• C. The staff turn the client to the unaffected side and the nurse asks the client to dorsiflex the foot on the affected leg
• D. The nurse asks the client to dorsiflex the foot on the affected leg

Correct answer: C

Rationale: The correct answer is C. Turning the client to the unaffected side helps prevent complications such as pressure ulcers. Dorsiflexion of the foot on the affected leg helps maintain proper alignment and prevent foot drop. The incorrect choices are A and D. Removing the foam boot multiple times per day can disrupt traction, and asking the client to dorsiflex the foot may not be appropriate without ensuring proper alignment and direction from the healthcare provider.

2. Which nutrient deficiency is most likely to be seen in patients with chronic alcoholism?

• A. Vitamin C
• B. Vitamin D
• C. Vitamin B12
• D. Vitamin B1

Correct answer: D

Rationale: In patients with chronic alcoholism, the most likely nutrient deficiency is Vitamin B1 (thiamine), not Vitamin B12. Chronic alcoholism often leads to Vitamin B1 deficiency, causing conditions like Wernicke's encephalopathy. While other vitamin deficiencies can also occur in chronic alcoholism, such as Vitamin C and Vitamin D, Vitamin B1 deficiency is more commonly associated with alcoholism.

3. A client has been given instructions about ferrous sulfate. Which statement made by the client would indicate the client needs further education?

• A. I will take this medication on an empty stomach.
• B. I will take the morning dose 1 hour before breakfast.
• C. I will need to avoid taking this medication with coffee.
• D. I will take antacids if needed, 2 hours after I take ferrous sulfate.

Correct answer: A

Rationale: The correct answer is A. Ferrous sulfate should be taken on an empty stomach to improve absorption. Choice A is incorrect as taking the medication with a full glass of milk would impair iron absorption. Choices B, C, and D are all correct statements regarding the administration of ferrous sulfate. Choice B ensures proper timing before breakfast, choice C highlights avoiding coffee due to interference with iron absorption, and choice D correctly suggests taking antacids a few hours after ferrous sulfate to prevent potential interactions.

4. The nurse is caring for clients on a cardiac floor. Which client should the nurse assess first?

• A. The client with three (3) unifocal PVCs in a minute
• B. The client diagnosed with coronary artery disease who wants to ambulate
• C. The client diagnosed with mitral valve prolapse with an audible S3
• D. The client diagnosed with pericarditis who is in normal sinus rhythm

Correct answer: C

Rationale: The correct answer is C because an audible S3 in a client with mitral valve prolapse could indicate heart failure, which requires immediate assessment. Choice A is less urgent as occasional unifocal PVCs are common. Choice B is important but can be addressed after the client with an audible S3. Choice D, a client with pericarditis in normal sinus rhythm, is stable compared to a client with potential heart failure symptoms.

5. A nurse administers albuterol to a child with asthma. For what common side effect should the nurse monitor the child?

• A. Flushing
• B. Dyspnea
• C. Tachycardia
• D. Hypotension

Correct answer: C

Rationale: The correct answer is C, Tachycardia. Albuterol, a bronchodilator used to treat asthma, commonly causes tachycardia as a side effect. Flushing (choice A) is not a typical side effect of albuterol. Dyspnea (choice B) refers to difficulty breathing, which is a symptom of asthma but not a common side effect of albuterol. Hypotension (choice D) is low blood pressure, which is not a common side effect associated with albuterol use.

Similar Questions