Nursing Elites

1. Which statement made by the client indicates an understanding of the instructions regarding the administration of alendronate (Fosamax)?

• A. I will take the medication at bedtime to avoid stomach upset.
• B. I will take the medication with a full glass of water first thing in the morning.
• C. I will lie down for 30 minutes after taking the medication.
• D. I will take the medication with food to reduce stomach irritation.

Correct answer: B

Rationale: The correct answer is B. Alendronate (Fosamax) should be taken with a full glass of water in the morning to prevent esophageal irritation and ensure proper absorption. Choice A is incorrect because taking alendronate at bedtime increases the risk of esophageal irritation due to lying down. Choice C is incorrect because patients should remain upright for at least 30 minutes after taking alendronate to prevent esophageal irritation. Choice D is incorrect because alendronate should be taken on an empty stomach, not with food, to enhance absorption.

2. To prevent unnecessary hypoxia during suctioning of a tracheostomy, what must the nurse do?

• A. Apply suction for no more than 10 seconds
• B. Maintain sterile technique
• C. Lubricate 3 to 4 inches of the catheter tip
• D. Withdraw catheter in a circular motion

Correct answer: A

Rationale: The correct answer is to apply suction for no more than 10 seconds. Prolonged suctioning can lead to hypoxia, so it is essential to limit the suctioning time. Maintaining sterile technique (choice B) is important to prevent infections but is not directly related to preventing hypoxia during suctioning. Lubricating the catheter tip (choice C) helps with insertion but does not specifically address hypoxia prevention. Withdrawing the catheter in a circular motion (choice D) is not a standard practice during tracheostomy suctioning and does not help prevent hypoxia.

3. A male client with schizophrenia is socially reclusive and pacing in the hallway. What is the most important intervention for the nurse to implement?

• A. Take the client's temperature and blood pressure.
• B. Encourage the client to rest.
• C. Plan an activity that includes physical exercise.
• D. Carefully observe the client throughout the shift.

Correct answer: D

Rationale: The correct answer is to carefully observe the client throughout the shift. In this situation, the client's behavior suggests agitation and restlessness, which could potentially escalate. Observation is crucial to monitor any changes in behavior, assess for signs of distress, and ensure the client's safety. Taking the client's temperature and blood pressure (Choice A) may not address the immediate need for managing the client's behavior. Encouraging the client to rest (Choice B) might not be effective if the client is highly agitated. Planning an activity that includes physical exercise (Choice C) could exacerbate the situation rather than address the current behavior. Therefore, the priority is to observe the client closely to provide appropriate support and intervention as needed.

4. A client is receiving treatment for glaucoma. Which class of medications is commonly used to decrease intraocular pressure?

• A. Anticholinergics
• B. Beta blockers
• C. Alpha blockers
• D. Diuretics

Correct answer: D

Rationale: Diuretics are commonly used to decrease intraocular pressure in clients with glaucoma. They work by reducing the production of aqueous humor in the eye or by increasing its outflow. Anticholinergics (Choice A) are not typically used in the treatment of glaucoma and can even increase intraocular pressure. Beta blockers (Choice B) are also commonly used in glaucoma treatment as they reduce aqueous humor production. Alpha blockers (Choice C) are not the first-line treatment for glaucoma and are not as commonly used as diuretics or beta blockers.

5. A client has burns covering 40% of their total body surface area (TBSA). What is the nurse’s priority action?

• A. Monitor the client's urinary output hourly.
• B. Apply cool, moist dressings to the burned areas.
• C. Administer pain medication to reduce discomfort.
• D. Administer IV fluids to prevent hypovolemia.

Correct answer: A

Rationale: The correct answer is A: Monitor the client's urinary output hourly. Clients with burns covering a large percentage of their total body surface area are at high risk for hypovolemia due to fluid loss. Monitoring urinary output is crucial because it helps assess kidney function and fluid balance, providing essential information about the client's hemodynamic status. Applying cool, moist dressings (choice B) is important but not the priority over assessing fluid balance. Administering pain medication (choice C) is essential for comfort but not the priority over monitoring for potential complications like hypovolemia. Administering IV fluids (choice D) is important to prevent hypovolemia, but monitoring urinary output should be the priority to guide fluid resuscitation.

Similar Questions