Nursing Elites

1. After medicating the client for pain and collecting granules and stones from strained urine, which action is most important for the nurse to implement next?

• A. Send the calculi for laboratory analysis of stone composition.
• B. Evaluate the client for persistent pain.
• C. Assess the clarity of urine.
• D. Encourage high fluid intake to produce urine output of 2L/day.

Correct answer: A

Rationale: Sending the calculi for analysis is crucial in determining the type of stone present. Identifying the stone composition helps in developing an effective treatment plan and preventive measures to avoid future episodes of urolithiasis. This step is essential in providing targeted care for the client. Options B, C, and D are not the most important actions at this point. While evaluating for persistent pain is essential, determining the stone composition takes precedence to guide appropriate interventions.

2. The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to the start of the procedure?

• A. Verbalizes a fear of being in a confined space.
• B. Drank a glass of water in the past 2 hours.
• C. Reports left chest wall pain prior to admission.
• D. Experiences facial swelling after eating crab

Correct answer: C

Rationale: The correct answer is C. Left chest wall pain could indicate ongoing cardiac issues or instability, which needs to be assessed before proceeding with the procedure. This pain could be related to the heart and may suggest a potential risk during the angioplasty. Options A, B, and D do not directly relate to cardiac complications during the procedure, making them less urgent for immediate assessment. Fear of confined spaces, drinking water, and facial swelling after eating crab are not immediate risks to the client's safety in the context of a cardiac catheterization procedure.

3. After changing to a new brand of laundry detergent, an adult male reports that he has a fine itchy rash. Which assessment finding warrants immediate intervention by the nurse?

• A. Bilateral Wheezing
• B. Urticaria
• C. Peripheral edema
• D. Elevated blood pressure

Correct answer: B

Rationale: The correct answer is B: Urticaria. An itchy rash following a change in detergent may indicate an allergic reaction, specifically urticaria (hives), which requires immediate attention. Urticaria can be a sign of a severe allergic reaction, such as anaphylaxis. Bilateral wheezing (choice A) may suggest respiratory issues like asthma but is not directly related to the skin rash. Peripheral edema (choice C) and elevated blood pressure (choice D) are not typically associated with an allergic reaction to laundry detergent and would not be the priority assessment findings in this scenario.

4. A male client with cirrhosis has jaundice and pruritus. He tells the nurse that he has been soaking in hot baths at night with no relief of his discomfort. What action should the nurse take?

• A. Explain that the symptoms are caused by liver damage and can be managed
• B. Obtain a PRN prescription for an analgesic that the client can use for symptom relief
• C. Encourage the client to use cooler water and apply oil-based lotion after soaking
• D. Suggest that the client take brief showers and apply oil-based lotion after showering

Correct answer: D

Rationale: Cooler water and oil-based lotion can help relieve pruritus and improve comfort in clients with cirrhosis experiencing jaundice and pruritus. Hot baths can exacerbate itching, so it is important to suggest cooler showers instead. Choice A is incorrect because symptoms like pruritus can be managed. Choice B is not the most appropriate initial intervention for pruritus related to liver disease. Choice C suggests the use of calamine lotion, which may not be as effective as oil-based lotion for relieving pruritus in this case.

5. Which client is at the greatest risk for developing delirium?

• A. An adult client who cannot sleep due to constant pain
• B. An older client who attempted suicide 1 month ago
• C. A young adult who takes antipsychotic medications twice a day
• D. A middle-aged woman who uses a tank for supplemental oxygen

Correct answer: B

Rationale: The correct answer is B because older adults are at higher risk for delirium, especially following a recent suicide attempt, which can be a significant stressor. Choice A is less likely to develop delirium solely due to difficulty sleeping; delirium is more complex and multifactorial. Choice C, a young adult taking antipsychotic medications, may be at risk for other conditions but not necessarily delirium. Choice D, a middle-aged woman using supplemental oxygen, is not directly linked to an increased risk of delirium compared to the older client who recently attempted suicide.

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