Nursing Elites

1. A client is admitted with the diagnosis of Wernicke’s syndrome. What assessment finding should the nurse use in planning the client’s care?

• A. Right lower abdominal pain
• B. Confusion
• C. Depression
• D. Peripheral neuropathy

Correct answer: B

Rationale: Confusion is a key symptom of Wernicke’s syndrome, which is due to thiamine deficiency. Wernicke’s syndrome is characterized by a triad of symptoms known as the classic triad, which includes confusion, ataxia, and ophthalmoplegia. Right lower abdominal pain, depression, and peripheral neuropathy are not typically associated with Wernicke’s syndrome, making them incorrect choices for this question.

2. A male client admitted three days ago with respiratory failure is intubated and receiving 40% oxygen per facemask. Currently, his temperature is 99°F, capillary refill is less than 4 seconds, and respiratory effort is within normal limits. What outcome should the nurse evaluate to measure for successful extubation?

• A. Exhibits adequate tissue perfusion
• B. Remains free of injury
• C. Remains free of infection
• D. Maintains effective breathing pattern

Correct answer: D

Rationale: Successful extubation is primarily measured by the client's ability to maintain an effective breathing pattern. This indicates that the client can adequately oxygenate and ventilate without the need for artificial airway support. Choices A, B, and C are important aspects of patient care but are not the primary outcomes to evaluate for successful extubation. Adequate tissue perfusion, freedom from injury, and prevention of infection are ongoing goals during the client's hospitalization but are not the immediate focus when considering extubation.

3. The nurse provides discharge teaching to a client who was recently diagnosed with diabetes mellitus (DM). After receiving the instructions, the client expresses understanding about when, how, and why to take his prescribed medications at home. Which intervention is most important for the nurse to implement?

• A. Review the purpose of medications prescribed for the client to take home with him
• B. Provide the client with a printed list of medications and a schedule for administration
• C. Send a list of medications taken while hospitalized to the client’s healthcare provider
• D. Offer to consult with the pharmacist about resources for reduced-price medications

Correct answer: B

Rationale: Providing the client with a printed list of medications and a schedule for administration is crucial to ensure adherence and understanding of the medication regimen at home. This intervention helps the client follow the prescribed treatment plan accurately. Choice A is not as essential since the client already understands when, how, and why to take the medications. Choice C is not a priority at this point as the client needs information for home medication management. Choice D, while helpful, is not the most important intervention compared to providing a clear list and schedule for medication administration.

4. The nurse is assessing an infant with pyloric stenosis. Which pathophysiological mechanism is the most likely consequence of this infant’s clinical picture?

• A. Metabolic acidosis
• B. Metabolic alkalosis
• C. Respiratory alkalosis
• D. Respiratory acidosis

Correct answer: B

Rationale: Pyloric stenosis often leads to metabolic alkalosis due to the loss of gastric acid from vomiting. Metabolic acidosis would not be expected in pyloric stenosis as there is no excessive acid accumulation. Respiratory alkalosis and respiratory acidosis are not typically associated with pyloric stenosis, making them incorrect choices.

5. The healthcare provider prescribes a fluid challenge of 0.9% sodium chloride 1,000 ml to be infused over 4 hours. The IV administration set delivers 10gtt/ml. How many gtt/minute should the nurse regulate the infusion? (Enter a numeric value only. If rounding is required, round to the nearest whole number.)

• A. 42
• B.
• C.
• D.

Correct answer: A

Rationale: To calculate the rate: (1000 ml / 4 hours) = 250 ml/hour; (250 ml/hour) / (60 minutes/hour) = 4.17 ml/minute; (4.17 ml/minute) * (10 gtt/ml) = 41.7 gtt/minute, rounded to 42 gtt/minute. Therefore, the nurse should regulate the infusion at 42 gtt/minute to deliver the prescribed fluid challenge accurately. The other choices are incorrect as they do not reflect the correct calculation based on the given information.

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