Nursing Elites

1. A client with cirrhosis is admitted with hepatic encephalopathy. Which clinical finding is most concerning?

• A. Confusion and altered mental status
• B. Increased abdominal girth
• C. Yellowing of the skin
• D. Peripheral edema

Correct answer: A

Rationale: Confusion and altered mental status are the most concerning clinical findings in a client with hepatic encephalopathy. These symptoms indicate worsening liver function and potential neurological complications, requiring immediate medical attention. Increased abdominal girth may suggest ascites, yellowing of the skin can indicate jaundice, and peripheral edema may be related to fluid retention, but in the context of hepatic encephalopathy, confusion and altered mental status take precedence due to the risk of rapid deterioration and the need for prompt management.

2. The mother of a one-month-old boy born at home brings the infant to his first well-baby visit. The infant was born two weeks after his due date and is described as a 'good, quiet baby' who almost never cries. To assess for hypothyroidism, what question is most important for the nurse to ask the mother?

• A. Has your son had any immunizations yet?
• B. Is your son sleepy and difficult to feed?
• C. Are you breastfeeding or bottle-feeding your son?
• D. Were any relatives born with birth defects?

Correct answer: B

Rationale: The correct answer is B. Excessive sleepiness and difficulty feeding can be signs of hypothyroidism in infants. Asking about the infant's sleepiness and feeding pattern is crucial in assessing for hypothyroidism. Choice A is incorrect because immunizations are not directly related to hypothyroidism. Choice C is about feeding method and not specific to hypothyroidism. Choice D is unrelated as it asks about relatives with birth defects, which does not directly assess the infant's condition.

3. A client with type 2 diabetes is admitted with hyperglycemic hyperosmolar syndrome (HHS). Which intervention should the nurse implement first?

• A. Administer intravenous fluids.
• B. Monitor the client's urine output.
• C. Obtain a blood glucose level.
• D. Administer 50% dextrose IV push.

Correct answer: D

Rationale: The correct answer is to administer 50% dextrose IV push first. In hyperglycemic hyperosmolar syndrome, the main goal is to rapidly reduce blood glucose levels to prevent further complications. Administering dextrose intravenously can help reverse the effects of high blood glucose levels quickly. Administering intravenous fluids, monitoring urine output, and obtaining a blood glucose level are important interventions but are not the first priority in treating HHS. Administering 50% dextrose IV push takes precedence as it directly addresses the elevated blood glucose levels.

4. In preparing assignments for the shift, which client is best for the charge nurse to assign to a practical nurse (PN)?

• A. An older client who fell yesterday and is now complaining of diplopia.
• B. An adult newly diagnosed with type 1 diabetes and high cholesterol.
• C. A client with pancreatic cancer who is experiencing intractable pain.
• D. An older client post-stroke who is aphasic with right-sided hemiplegia.

Correct answer: D

Rationale: The best client for the charge nurse to assign to a practical nurse (PN) is an older client post-stroke who is aphasic with right-sided hemiplegia. This client is stable and suitable for care by a PN under supervision. Choices A, B, and C present clients with more complex and acute conditions that would require a higher level of nursing expertise and intervention.

5. A nurse is caring for a client with an indwelling urinary catheter. Which intervention is most important to include in the client's plan of care?

• A. Ensure the catheter is below the level of the bladder at all times.
• B. Change the catheter bag every 48 hours.
• C. Cleanse the perineal area daily.
• D. Perform catheter care daily.

Correct answer: A

Rationale: The correct answer is to ensure the catheter is always below the level of the bladder. Placing the catheter tubing above the level of the bladder can lead to backflow of urine, causing urinary tract infections. Changing the catheter bag every 48 hours is important but not as crucial as maintaining proper catheter positioning. Cleaning the perineal area daily and performing catheter care are essential tasks but do not directly address the prevention of complications associated with catheter placement.

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