Nursing Elites

1. A client is admitted with hepatitis A (HAV) and dehydration. Subjective symptoms include anorexia, fatigue, and malaise. What additional assessment should the nurse expect to find during the preicteric phase?

• A. RUQ abdominal pain
• B. Clay-colored stools
• C. Icteric sclera
• D. Pruritus

Correct answer: A

Rationale: During the preicteric phase of hepatitis A, the nurse should expect to find RUQ (right upper quadrant) abdominal pain. This pain is common in the early phase of hepatitis A and is associated with liver inflammation. Clay-colored stools (Choice B) are typically seen in the icteric phase when there is a lack of bile flow. Icteric sclera (Choice C) refers to yellowing of the eyes, which is a characteristic of the icteric phase. Pruritus (Choice D), which is itching of the skin, is also more commonly associated with the icteric phase when bile salts accumulate in the skin.

2. A female client reports she has not had a bowel movement for 3 days, but now is defecating frequent small amounts of liquid stool. Which action should the nurse implement?

• A. Digitally check the client for a fecal impaction
• B. Increase fluid intake to promote bowel regularity
• C. Provide a high-fiber diet to facilitate bowel movements
• D. Administer a stool softener

Correct answer: A

Rationale: The correct answer is A: Digitally check the client for a fecal impaction. Small, frequent liquid stools following constipation may indicate a fecal impaction. This intervention is crucial to assess and address a potential impaction promptly. Choices B, increasing fluid intake, and C, providing a high-fiber diet, may help with bowel regularity in general cases, but they don't directly address the urgent concern of a possible impaction. Choice D, administering a stool softener, is not appropriate as the first action when a fecal impaction is suspected; it could worsen the condition by causing further liquid stool output without addressing the impaction.

3. A client with a BMI of 60.2 kg/m² is admitted to the intensive care unit 3 weeks after gastric bypass with gastric rupture and impending multiple organ dysfunction syndrome (MODS). What should the nurse prepare to implement first?

• A. Mechanical ventilation
• B. Platelet transfusion
• C. Loop diuretic therapy
• D. Cyanocobalamin administration

Correct answer: A

Rationale: In this critical situation with gastric rupture and impending MODS, the priority intervention should be mechanical ventilation. This client is at risk of respiratory compromise due to the severity of the condition. Platelet transfusion (Choice B) is not the priority as there is no indication of significant bleeding. Loop diuretic therapy (Choice C) and cyanocobalamin administration (Choice D) are not the immediate priorities in this scenario and would not address the urgent need for respiratory support.

4. A heparin infusion is prescribed for a client who weighs 220 pounds. After administering a bolus dose of 80 units/kg, the nurse calculates the infusion rate for the heparin sodium at 18 units/kg/hour. The available solution is Heparin Sodium 25,000 units in 5% Dextrose Injection 250 ml. The nurse should program the infusion pump to deliver how many ml/hour?

• A. 18
• B. 27
• C. 36
• D. 45

Correct answer: B

Rationale: To calculate the infusion rate, first, find the total dose required per hour, which is the patient's weight (220 pounds) multiplied by the prescribed rate (18 units/kg/hour). This equals 3960 units/hour. Next, determine how many ml of the solution contain 25,000 units; this is 250 ml. Divide the total dose required per hour (3960 units) by the units per ml (25,000 units/250 ml) to find how many ml are needed per hour. This results in 27 ml/hour. Therefore, the nurse should program the infusion pump to deliver 27 ml/hour. Choice A (18) is incorrect as it does not account for the concentration of the heparin solution. Choices C (36) and D (45) are incorrect as they do not reflect the accurate calculations based on the patient's weight and the heparin concentration in the solution.

5. An adult client with severe depression was admitted to the psychiatric unit yesterday evening. Although the client used to run a year ago, his spouse states that the client no longer runs but sits and watches television most of the day. Which is most important for the nurse to include in this client’s plan of care for today?

• A. Assist the client in identifying goals for the day
• B. Encourage the client to participate in a team sport for one hour
• C. Schedule the client for a group session that focuses on self-esteem
• D. Help the client develop a list of daily affirmations

Correct answer: A

Rationale: Assisting the client in identifying goals for the day is the most important aspect of the plan of care for a client with severe depression. Setting achievable daily goals helps engage the client in activities and promotes a sense of accomplishment, which can contribute to gradual improvement in their condition. Encouraging participation in team sports may be overwhelming for a client with severe depression as it requires a significant level of energy and motivation that the client may not possess at this time. Group sessions focusing on self-esteem and daily affirmations are beneficial interventions, but they may not have an immediate impact compared to setting achievable daily goals that can provide a sense of purpose and achievement for the client.

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