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. The client is unable to void, and the plan of care sets an objective for the client to ingest at least 1000 mL of fluid between 7:00 am and 3:30 pm. Which client response should the nurse document to indicate a successful outcome?

• A. Drinks adequate fluids.
• B. Void without difficulty.
• C. Feels less thirsty.
• D. Drinks 240 mL of fluid five times during the shift.

Correct answer: D

Rationale: The correct answer is D. Drinking 240 mL of fluid five times during the shift indicates a fluid intake of 1200 mL, which exceeds the minimum objective of at least 1000 mL. The client meeting or exceeding the fluid intake goal is a clear indicator of a successful outcome. Choices A, B, and C are incorrect because simply drinking adequate fluids, voiding without difficulty, or feeling less thirsty do not directly demonstrate meeting the specific objective of fluid intake set in the care plan.

3. The nurse is preparing a teaching plan for a client who is newly diagnosed with hypothyroidism. Which instruction should the nurse include?

• A. Take levothyroxine (Synthroid) at bedtime.
• B. Increase fiber intake to prevent constipation.
• C. Take the medication on an empty stomach.
• D. Take a double dose if a dose is missed.

Correct answer: C

Rationale: The correct instruction for a client newly diagnosed with hypothyroidism is to take the medication on an empty stomach. This is important because taking levothyroxine on an empty stomach ensures better absorption of the medication. Choice A, taking levothyroxine at bedtime, is incorrect as it does not promote optimal absorption. Choice B, increasing fiber intake to prevent constipation, is important but not the priority when it comes to medication administration. Choice D, taking a double dose if a dose is missed, is dangerous and should never be advised as it can lead to overdose and serious side effects.

4. The nurse obtains a heart rate of 92 and a blood pressure of 110/76 before administering a scheduled dose of verapamil (Calan) for a client with atrial flutter. Which action should the nurse implement?

• A. Administer the dose as prescribed.
• B. Hold the medication.
• C. Call the healthcare provider.
• D. Repeat the vital signs in 30 minutes.

Correct answer: A

Rationale: The correct action is to administer the dose as prescribed. Verapamil slows sinoatrial nodal automaticity and delays atrioventricular nodal conduction, which helps in slowing the ventricular rate. The heart rate of 92 and blood pressure of 110/76 are within an acceptable range for administering verapamil in a client with atrial flutter. Holding the medication, calling the healthcare provider, or repeating the vital signs in 30 minutes are not necessary based on the vital signs obtained and the action of verapamil in this scenario.

5. The healthcare professional is providing education on healthy eating habits to a group of adolescents. Which strategy is most likely to be effective?

• A. lecturing about the dangers of unhealthy eating
• B. distributing pamphlets on healthy food choices
• C. involving the adolescents in meal planning and preparation
• D. showing a documentary on the benefits of a healthy diet

Correct answer: C

Rationale: Involving adolescents in meal planning and preparation is a more effective strategy as it actively engages them in the learning process. This approach allows adolescents to have hands-on experience, make informed choices, and develop a sense of ownership over their dietary decisions. Lecturing about dangers or showing documentaries may not be as engaging or interactive, making it less likely for adolescents to retain and apply the information provided. Distributing pamphlets can be informative but lacks the interactive and experiential aspect that involving them in meal planning and preparation offers.

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