Nursing Elites

1. A client with a history of peptic ulcer disease is admitted with severe abdominal pain. Which assessment finding requires immediate intervention?

• A. Epigastric tenderness.
• B. Bowel sounds are hypoactive.
• C. The client reports sudden, severe abdominal pain.
• D. Bowel sounds are hyperactive.

Correct answer: C

Rationale: The correct answer is C. Sudden, severe abdominal pain can indicate a perforated ulcer, which is a medical emergency requiring immediate intervention. Epigastric tenderness (choice A) may be expected in a client with peptic ulcer disease but does not necessarily require immediate intervention. Hypoactive bowel sounds (choice B) are concerning but not as urgent as sudden, severe abdominal pain. Hyperactive bowel sounds (choice D) are more indicative of conditions like gastroenteritis rather than a perforated ulcer, making it a less critical finding compared to sudden, severe abdominal pain.

2. A client with a history of alcoholism is admitted with pancreatitis. Which assessment finding is most important for the nurse to report to the healthcare provider?

• A. Nausea and vomiting.
• B. Epigastric pain radiating to the back.
• C. Temperature of 102°F (38.9°C).
• D. Mild jaundice.

Correct answer: C

Rationale: A temperature of 102°F (38.9°C) is the most important assessment finding to report to the healthcare provider in a client with pancreatitis and a history of alcoholism. Fever in this context can indicate infection, which is a serious complication requiring immediate intervention. Nausea and vomiting (choice A) are common symptoms of pancreatitis but may not require immediate intervention unless severe. Epigastric pain radiating to the back (choice B) is a classic symptom of pancreatitis and should be addressed, but a fever takes precedence. Mild jaundice (choice D) may be present in pancreatitis but is not as urgent as a high temperature signaling possible infection.

3. After coronary artery bypass graft surgery, a male client is admitted to the coronary care unit. Which nursing diagnosis is of the highest priority?

• A. Ineffective breathing pattern.
• B. Impaired gas exchange.
• C. Acute pain.
• D. Risk for infection.

Correct answer: B

Rationale: Impaired gas exchange is the highest priority nursing diagnosis because it directly impacts the client's oxygenation. Following coronary artery bypass graft surgery, ensuring adequate oxygen exchange is crucial for the client's recovery. Ineffective breathing pattern, although important, may not be as critical as impaired gas exchange in the immediate postoperative period. Acute pain, while significant, can be managed effectively with appropriate interventions and is not as emergent as addressing impaired gas exchange. Risk for infection is also a valid concern post-surgery, but ensuring optimal gas exchange takes precedence to prevent complications associated with inadequate oxygenation.

4. A client with type 2 diabetes mellitus is admitted with hyperosmolar hyperglycemic state (HHS). Which laboratory result requires immediate intervention?

• A. Serum osmolality of 320 mOsm/kg.
• B. Serum glucose of 600 mg/dL.
• C. Serum potassium of 4.5 mEq/L.
• D. Serum sodium of 140 mEq/L.

Correct answer: B

Rationale: A serum glucose level of 600 mg/dL is extremely high in a client with hyperosmolar hyperglycemic state (HHS) and poses a significant risk of serious complications such as dehydration, coma, and electrolyte imbalances. Rapid intervention is crucial to normalize the glucose level and prevent further deterioration. Serum osmolality of 320 mOsm/kg, serum potassium of 4.5 mEq/L, and serum sodium of 140 mEq/L, while important to monitor in HHS, do not represent an immediate life-threatening condition that requires urgent intervention compared to the critically high glucose level.

5. Following an emergency Cesarean delivery, the nurse encourages the new mother to breastfeed her newborn. The client asks why she should breastfeed now. Which information should the nurse provide?

• A. To bond with the baby.
• B. To help the baby latch on better.
• C. To stimulate contraction of the uterus.
• D. To promote milk production.

Correct answer: C

Rationale: The correct answer is C: 'To stimulate contraction of the uterus.' After delivery, breastfeeding helps in stimulating the release of oxytocin, which triggers the contraction of the uterus. This contraction is crucial to prevent uterine hemorrhage and facilitate the involution process. Choices A, B, and D are incorrect. While breastfeeding can indeed help in bonding with the baby and promoting milk production, in the immediate postpartum period after a Cesarean section, the priority is to ensure uterine contraction to prevent complications.

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