Nursing Elites

1. To evaluate the client's therapeutic response to lactulose for signs of hepatic encephalopathy, which assessment should the nurse obtain?

• A. Level of consciousness
• B. Percussion of abdomen
• C. Serum electrolytes
• D. Blood glucose

Correct answer: A

Rationale: The correct answer is A: Level of consciousness. Monitoring the client's level of consciousness is essential in evaluating the effectiveness of lactulose in treating hepatic encephalopathy. Lactulose helps reduce blood ammonia levels by promoting the excretion of ammonia in the stool, thereby improving the client's mental status. Assessing the client's level of consciousness helps determine if the medication is effectively managing hepatic encephalopathy symptoms. Choices B, percussion of the abdomen, and D, blood glucose, are not directly related to evaluating the therapeutic response to lactulose for hepatic encephalopathy. Choice C, serum electrolytes, while important in overall patient care, is not the primary assessment to determine lactulose's effectiveness in treating hepatic encephalopathy.

2. The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized elderly client with an indwelling urinary catheter every two hours. What additional action should the nurse instruct the UAP to take each time the client is turned?

• A. Empty the urinary drainage bag
• B. Feed the client a snack
• C. Offer the client oral fluids
• D. Assess the breath sounds

Correct answer: A

Rationale: The correct additional action the nurse should instruct the UAP to take each time the immobilized elderly client with an indwelling urinary catheter is turned is to empty the urinary drainage bag. This action helps to prevent backflow of urine, reduces the risk of infection, and prevents bladder distention, which are crucial for the client's comfort and health. Choices B, C, and D are incorrect as they are not directly related to the care of a client with an indwelling urinary catheter. Feeding a snack, offering oral fluids, or assessing breath sounds are important aspects of care but not the immediate action needed when turning a client with an indwelling urinary catheter to prevent complications.

3. A client admitted to the intensive care unit with syndrome of inappropriate antidiuretic hormone (SIADH) has developed osmotic demyelination. Which intervention should the nurse implement first?

• A. Patch one eye.
• B. Reorient often.
• C. Range of motion.
• D. Evaluate swallow

Correct answer: B

Rationale: Frequent reorientation is crucial for clients with neurological impairments from osmotic demyelination to prevent confusion and assist with orientation. It helps maintain a proper sense of time, place, and person, reducing disorientation. Patching one eye (Choice A) is not a priority intervention for osmotic demyelination and does not address the immediate need for reorientation. Range of motion exercises (Choice C) may be important for overall care, but reorientation takes precedence due to its impact on neurological functioning. Evaluating swallow (Choice D) is not the primary intervention needed for osmotic demyelination; it is essential but not the first priority.

4. A client with active tuberculosis (TB) is receiving isoniazid (INH) and rifampin (RMP) daily, so direct observation therapy (DOT) is initiated while the client is hospitalized. Which instruction should the nurse provide this client?

• A. Describe feelings about taking daily medications
• B. Take medications in the presence of the nurse
• C. Notify the nurse after self-medication is completed
• D. Keep a daily record of all medications taken

Correct answer: B

Rationale: The correct instruction for the nurse to provide the client undergoing direct observation therapy for TB is to take medications in the presence of the nurse. This approach ensures that the client is actually taking the medications as prescribed, reducing the risk of noncompliance. Choice A is incorrect because the focus should be on ensuring the client physically takes the medications rather than discussing feelings. Choice C is incorrect as it does not ensure direct observation. Choice D is incorrect because self-reporting or keeping a record does not guarantee that the client is actually taking the medications.

5. Two days after an abdominal hysterectomy, an elderly female with diabetes has a syncopal episode. The nurse determines that her vital signs are within normal limits, but her blood sugar is 325 mg/dL or 18.04 mmol/L (SI). What intervention should the nurse implement first?

• A. Administer regular insulin per sliding scale
• B. Cancel the client's dinner tray
• C. Give the client 4 ounces (120 mL) of orange juice
• D. Administer the next scheduled dose of metformin

Correct answer: A

Rationale: In this case, the nurse should implement the intervention of administering regular insulin per sliding scale. High blood sugar levels, as indicated by a reading of 325 mg/dL, require insulin administration to prevent complications such as hyperglycemia. Canceling the client's dinner tray (choice B) would not address the immediate need to lower the blood sugar level. Giving the client orange juice (choice C) might further increase the blood sugar level as it contains sugar. Administering the next scheduled dose of metformin (choice D) is not appropriate as metformin is not typically used for acute management of high blood sugar levels.

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