Nursing Elites

1. A client is admitted with a suspected bowel obstruction. What assessment finding should the nurse report immediately?

• A. Absent bowel sounds in all quadrants.
• B. Distended abdomen with a firm, rigid feel.
• C. Frequent episodes of nausea and vomiting.
• D. Hyperactive bowel sounds and abdominal cramping.

Correct answer: B

Rationale: A distended abdomen with a firm, rigid feel is a concerning sign that suggests a complication such as bowel perforation, which requires immediate intervention. Absent bowel sounds can be expected in bowel obstructions but are not as urgent as a rigid abdomen. Frequent episodes of nausea and vomiting are common with bowel obstructions but do not indicate an immediate life-threatening complication. Hyperactive bowel sounds and abdominal cramping are more indicative of bowel obstruction rather than a complication requiring immediate attention.

2. The nurse is teaching a client about lifestyle changes to manage hypertension. Which of the following should be emphasized?

• A. Increase daily intake of sodium.
• B. Exercise regularly and maintain a healthy weight.
• C. Reduce intake of potassium-rich foods.
• D. Drink alcohol in moderation.

Correct answer: B

Rationale: The correct answer is B. Regular exercise and maintaining a healthy weight are crucial lifestyle changes in managing hypertension. Exercise helps lower blood pressure and improves heart health, while maintaining a healthy weight reduces the risk of hypertension. Choices A, C, and D are incorrect. Increasing daily intake of sodium can elevate blood pressure, reducing intake of potassium-rich foods is not recommended as potassium helps lower blood pressure, and drinking alcohol should be limited or avoided as it can raise blood pressure.

3. The nurse is assessing a client with a new diagnosis of hyperthyroidism. Which assessment finding should the nurse expect?

• A. Decreased heart rate
• B. Increased appetite
• C. Cold intolerance
• D. Weight gain

Correct answer: B

Rationale: In hyperthyroidism, there is an increase in metabolism, leading to symptoms such as increased appetite, weight loss, and heat intolerance. Therefore, the nurse should expect an increased appetite in a client with hyperthyroidism. Choices A, C, and D are incorrect because decreased heart rate and cold intolerance are more commonly associated with hypothyroidism, while weight gain is not typically seen in hyperthyroidism.

4. A client with heart failure is prescribed digoxin and reports nausea. What is the nurse's first action?

• A. Administer an anti-nausea medication as prescribed.
• B. Assess the client's digoxin level immediately.
• C. Assess the client’s apical pulse and hold the next dose if it's below 60 bpm.
• D. Instruct the client to reduce their fluid intake.

Correct answer: B

Rationale: When a client on digoxin reports nausea, it can be a sign of digoxin toxicity. The priority action for the nurse is to assess the client's digoxin level immediately. This assessment will help determine if the nausea is related to digoxin toxicity, requiring a dosage adjustment. Administering an anti-nausea medication (Choice A) does not address the underlying issue of potential digoxin toxicity. Assessing the client's apical pulse (Choice C) is important in general digoxin monitoring but not the first action when nausea is reported. Instructing the client to reduce fluid intake (Choice D) is not the initial response to nausea in a client taking digoxin.

5. A client presents with severe dehydration due to prolonged vomiting. What is the nurse's priority intervention?

• A. Encourage the client to drink clear fluids.
• B. Assess the client's skin turgor and mucous membranes.
• C. Monitor the client's vital signs frequently.
• D. Administer an antiemetic as prescribed.

Correct answer: B

Rationale: The correct answer is to assess the client's skin turgor and mucous membranes. When a client presents with severe dehydration, assessing skin turgor (elasticity of the skin) and mucous membranes (such as checking for dryness in the mouth) is crucial in determining the extent of dehydration. Encouraging the client to drink clear fluids (Choice A) may be important but assessing dehydration severity takes precedence. Monitoring vital signs (Choice C) is essential but assessing dehydration status comes first. Administering an antiemetic (Choice D) addresses vomiting but does not directly assess dehydration.

Similar Questions