Nursing Elites

1. A client in the oliguric phase of acute renal failure (ARF) has a 24-hour urine output of 400 ml. How much oral intake should the nurse allow this client to have during the next 24 hours?

• A. Encourage oral fluids as tolerated
• B. Decrease oral intake to 200 ml
• C. Allow the client to have exactly 400 ml oral intake
• D. Limit oral intake to 900 to 1,000 ml

Correct answer: D

Rationale: In the oliguric phase of acute renal failure (ARF), the goal is to prevent fluid overload. Since the client has a low urine output of 400 ml in 24 hours, limiting oral intake to 900 to 1,000 ml is appropriate. Encouraging unrestricted oral fluids (Choice A) can exacerbate fluid overload. Decreasing oral intake to 200 ml (Choice B) would be too restrictive and may lead to dehydration. Allowing the client to have exactly 400 ml oral intake (Choice C) would not account for other sources of fluid intake and output, potentially resulting in fluid imbalance.

2. An adult male is admitted to the psychiatric unit from the emergency department because he is in the manic disorder. He has lost 10 pounds in the last two weeks and has not bathed in a week because he has been 'trying to start a new business' and is 'too busy to eat.' He is alert and oriented to time, place and person, but not situation. Which nursing diagnosis has the greatest priority?

• A. Self-care deficit
• B. Disturbed sleep pattern
• C. Disturbed thought processes
• D. Imbalanced nutrition

Correct answer: D

Rationale: Imbalanced nutrition is the most critical nursing diagnosis to address in this scenario. The patient's significant weight loss and neglect of basic needs, such as eating and personal hygiene, indicate a severe imbalance in nutrition. Addressing this issue is crucial to prevent further health deterioration. Self-care deficit, disturbed sleep pattern, and disturbed thought processes are important but secondary concerns compared to the immediate risk posed by imbalanced nutrition. While self-care deficit and disturbed sleep pattern are valid concerns, the patient's weight loss and neglect of basic needs take precedence. Disturbed thought processes are also significant but addressing the imbalanced nutrition is more urgent in this context.

3. Which action should the nurse include in the plan of care for a client who is receiving acyclovir (Zovirax) IV for the treatment of herpes zoster (shingles)?

• A. Initiate cardiac telemetry monitoring
• B. Maintain continuous pulse oximetry
• C. Perform capillary glucose measurements
• D. Monitor serum creatinine levels

Correct answer: D

Rationale: The correct answer is to monitor serum creatinine levels. Acyclovir can potentially impact kidney function, making it essential to monitor serum creatinine levels to assess renal function. Option A, initiating cardiac telemetry monitoring, is not directly related to acyclovir administration for herpes zoster. Option B, maintaining continuous pulse oximetry, is more relevant in assessing respiratory status rather than monitoring for acyclovir-related side effects. Option C, performing capillary glucose measurements, is not directly associated with acyclovir therapy for herpes zoster.

4. The nurse-manager of a perinatal unit is notified that one client from the medical-surgical unit needs to be transferred to make room for new admissions. Which client should the nurse recommend for transfer to the antepartal unit?

• A. A 45-year-old with chronic hepatitis B.
• B. A 35-year-old with lupus erythematosus
• C. A 19-year-old diagnosed with rubella
• D. A 25-year-old with herpes lesions of the vulva

Correct answer: B

Rationale: The correct answer is B because a client with lupus erythematosus can be safely transferred to the antepartal unit as this condition does not pose a significant risk to other patients or staff. Choices A, C, and D should not be recommended for transfer to the antepartal unit due to the potential risks they may pose to pregnant women and their unborn babies. Chronic hepatitis B, rubella, and herpes lesions of the vulva can be contagious and harmful in the perinatal setting.

5. One hour after delivery, the nurse is unable to palpate the uterine fundus of a client and notes a large amount of lochia on the perineal pad. Which intervention should the nurse implement first?

• A. Empty the bladder using an indwelling urinary catheter
• B. Increase the rate of the IV containing oxytocin (Pitocin)
• C. Assess for shock by determining the blood pressure
• D. Perform gentle massage at the level of the umbilicus

Correct answer: D

Rationale: Gentle massage at the level of the umbilicus is the initial intervention to help contract the uterus and reduce bleeding, which is crucial in managing postpartum hemorrhage. Emptying the bladder can help with fundal displacement, but massage should be done first to stimulate uterine contractions. Increasing the IV oxytocin rate is a possible intervention but not the initial priority. Assessing for shock is important, but addressing the uterine atony through massage takes precedence to prevent further hemorrhage.

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