Nursing Elites

1. What information should the nurse include in the discharge teaching plan of a client with low back pain who is taking cyclobenzaprine to control muscle spasms?

• A. Take this medication with or without food
• B. Avoid using heat or ice on injured muscles while taking this medication
• C. Use cold and allergy medications only as directed by a healthcare provider
• D. Discontinue all nonsteroidal anti-inflammatory medications

Correct answer: C

Rationale: The correct answer is C: 'Use cold and allergy medications only as directed by a healthcare provider.' It is essential to inform the client not to self-medicate with cold and allergy medications or make changes without consulting a healthcare provider to prevent potential drug interactions or adverse effects. Choice A is incorrect because cyclobenzaprine can be taken with or without food, so there is no specific requirement to take it on an empty stomach. Choice B is incorrect because using heat or ice on injured muscles while taking cyclobenzaprine is generally safe and can help with symptom management. Choice D is also incorrect because discontinuing nonsteroidal anti-inflammatory medications should be done under the guidance of a healthcare provider, but it is not a direct concern related to taking cyclobenzaprine for muscle spasms.

2. A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic episodes and a glycosylated hemoglobin (HbA1c) of 10%. Insulin glargine 10 units subcutaneously once a day at bedtime and a sliding scale with insulin aspart q6h are prescribed. What action should the nurse include in this client’s plan of care?

• A. Perform fingerstick glucose assessment q6h with meals
• B. Mix bedtime dose of insulin glargine with insulin aspart sliding scale dose
• C. Review proper foot care and prevention of injury with the client
• D. Avoid contaminating the insulin aspart for IV use

Correct answer: A

Rationale: Performing fingerstick glucose assessments q6h with meals is essential in monitoring the client's blood glucose levels closely, especially when managing hyperglycemic episodes and adjusting insulin doses with a sliding scale. This action helps in determining the effectiveness of the prescribed insulin regimen. Reviewing proper foot care and preventing injury is important for long-term diabetic management but not the immediate priority in this scenario. Mixing insulin glargine with insulin aspart is not recommended, as they are different types of insulin with distinct mechanisms of action. Ensuring the availability of insulin aspart for IV use is not relevant to the client's current care plan.

3. The nurse is measuring the output of an infant admitted for vomiting and diarrhea. During a 12-hour shift, the infant drinks 4 ounces of Pedialyte, vomits 25 ml, and voids twice. The dry diaper weighs 105 grams. Which computer documentation should the nurse enter in the infant’s record?

• A. Subtract vomitus from 120 ml Pedialyte, then document 95 ml oral intake.
• B. Compare the difference between the infant’s current weight and admission weight.
• C. Document on the flow sheet that the infant voided twice and vomited 25 ml.
• D. Calculate the difference in wet and dry diapers and document 80 ml urine.

Correct answer: C

Rationale: The correct answer is to document on the flow sheet that the infant voided twice and vomited 25 ml. This choice accurately reflects the need for accurate documentation of intake and output, essential for monitoring the infant's hydration status. Choice A is incorrect because the oral intake should not be calculated by subtracting vomitus from the oral intake. Choice B is incorrect because it does not address the specific documentation related to the infant's output. Choice D is incorrect as it focuses on calculating urine output based on diaper weight, which is not the primary concern in this scenario.

4. A client with a history of chronic obstructive pulmonary disease (COPD) is admitted to the hospital. The client is experiencing difficulty breathing and is very anxious. The nurse notes that the client’s oxygen saturation is 88% on room air. Which action should the nurse implement first?

• A. Place the client in a high Fowler’s position
• B. Administer supplemental oxygen
• C. Perform a thorough respiratory assessment
• D. Start an IV infusion of normal saline

Correct answer: B

Rationale: Administering supplemental oxygen is the first priority to address low oxygen saturation and ease breathing. In a client with COPD experiencing difficulty breathing and anxiety with oxygen saturation at 88%, providing supplemental oxygen takes precedence over other actions. Placing the client in a high Fowler’s position may help with breathing but does not address the immediate need for increased oxygenation. Performing a thorough respiratory assessment is important but should come after stabilizing the client's oxygen levels. Starting an IV infusion of normal saline is not the priority in this situation and does not directly address the client's respiratory distress.

5. An older male was recently admitted to the rehabilitation unit with unilateral neglect syndrome as a result of a cerebrovascular accident (CVA). Which action should the nurse include in the plan of care?

• A. Provide additional light in the room to promote sensory stimulation
• B. Teach the client to turn his head from side to side for visual scanning
• C. Place a clock and calendar in the room to improve orientation
• D. Use hand and arm gestures to improve communication and comprehension

Correct answer: B

Rationale: Teaching the client to turn his head from side to side for visual scanning is essential in addressing unilateral neglect syndrome caused by a cerebrovascular accident. This action helps improve visual awareness and assists the client in overcoming the neglect of one side of the body. Providing additional light for sensory stimulation (Choice A) may not directly address the issue of unilateral neglect. Placing a clock and calendar in the room (Choice C) may be helpful for orientation but does not specifically target unilateral neglect. Using hand and arm gestures for communication (Choice D) may aid in communication but does not directly address the visual scanning deficits associated with unilateral neglect syndrome.

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