Nursing Elites

1. A client with acute pancreatitis is receiving nothing by mouth (NPO) status. What is the nurse's priority intervention?

• A. Administer antiemetic medication as prescribed.
• B. Monitor the client's intake and output.
• C. Provide mouth care to keep the client comfortable.
• D. Elevate the client's head of the bed.

Correct answer: B

Rationale: The correct answer is B: Monitor the client's intake and output. When a client with acute pancreatitis is on NPO status, the nurse's priority intervention is to monitor the client's intake and output. This is crucial to assess for signs of dehydration, electrolyte imbalances, and to ensure the client is responding appropriately to treatment. Administering antiemetic medication (choice A) may be necessary for managing nausea and vomiting but is not the priority over monitoring intake and output. Providing mouth care (choice C) and elevating the client's head of the bed (choice D) are important aspects of care but do not take precedence over monitoring intake and output to prevent complications in clients with NPO status due to acute pancreatitis.

2. The nurse has given discharge instructions to parents of a child on phenytoin (Dilantin). Which of the following statements suggests that the teaching was effective?

• A. We will call the health care provider if the child develops acne.
• B. Our child should brush and floss carefully after every meal.
• C. We will skip the next dose if vomiting or fever occur.
• D. When our child is seizure-free for 6 months, we can stop the medication.

Correct answer: B

Rationale: Phenytoin can cause gingival hyperplasia, so good oral hygiene is important to prevent complications.

3. The nurse is preparing to administer an intramuscular injection to an adult client. Which site should the nurse select?

• A. Deltoid muscle
• B. Ventrogluteal muscle
• C. Vastus lateralis muscle
• D. Dorsogluteal muscle

Correct answer: B

Rationale: The ventrogluteal site is preferred for intramuscular injections in adults because it is free from major blood vessels and nerves, reducing the risk of injury. The deltoid muscle can be used for smaller volumes of medication, primarily vaccines. The vastus lateralis muscle is commonly used in infants, toddlers, and young children. The dorsogluteal muscle site is discouraged due to its proximity to the sciatic nerve, increasing the risk of injury or nerve damage.

4. A 60-year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert but has not been able to void since he returned from surgery 6 hours ago. He received 1000 mL of IV fluid. Which action would be most likely to help him void?

• A. Have him drink several glasses of water
• B. Crede the bladder from the bottom to the top
• C. Assist him to stand by the side of the bed to void
• D. Wait 2 hours and have him try to void again

Correct answer: C

Rationale: Assisting the client to stand by the side of the bed to void is the most appropriate action in this situation. Standing to void often helps relieve the bladder, especially after surgery. Option A, having him drink several glasses of water, may not be as effective as the client might already be adequately hydrated. Option B, Crede maneuver, is a technique for emptying the bladder by applying manual pressure and is not the first-line intervention for a client who cannot void post-surgery. Option D, waiting 2 hours before trying to void again, may delay necessary intervention if the client is experiencing urinary retention.

5. An elderly client reports new-onset confusion, nausea, dysuria, and urgency. What action should the nurse take first?

• A. Initiate intravenous fluids
• B. Obtain a clean-catch midstream urine specimen
• C. Administer antibiotics
• D. Start a Foley catheter to obtain a sterile sample

Correct answer: B

Rationale: The correct first action for the nurse to take in this scenario is to obtain a clean-catch midstream urine specimen. The client's symptoms of confusion, nausea, dysuria, and urgency are suggestive of a urinary tract infection (UTI). To confirm the diagnosis and identify the causative organism, a urine specimen should be collected before initiating any treatment. Initiating intravenous fluids (Choice A) may be necessary later based on the client's condition but is not the initial priority. Administering antibiotics (Choice C) should be done after confirming the diagnosis through urine culture. Starting a Foley catheter (Choice D) to obtain a sterile sample is more invasive and should not be the first step in the assessment and management of a suspected UTI.

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