Nursing Elites

1. A client with cirrhosis is experiencing ascites and peripheral edema. What is the nurse's priority intervention?

• A. Administer furosemide as prescribed.
• B. Administer albumin to increase oncotic pressure.
• C. Elevate the client's legs to reduce swelling.
• D. Administer a sodium-restricted diet.

Correct answer: A

Rationale: The correct answer is A: Administer furosemide as prescribed. Administering furosemide, a loop diuretic, is the priority intervention in a client with cirrhosis experiencing ascites and peripheral edema. Furosemide helps promote diuresis and reduce fluid buildup in the body. Choice B, administering albumin to increase oncotic pressure, may be beneficial in some cases but is not the priority intervention for immediate fluid removal. Elevating the client's legs (Choice C) and administering a sodium-restricted diet (Choice D) are important aspects of managing edema and ascites but are not the priority interventions in this situation.

2. A nurse assesses a young adult in the emergency room following a motor vehicle accident. Which of the following neurological signs is of most concern?

• A. Flaccid paralysis
• B. Pupils fixed and dilated
• C. Diminished spinal reflexes
• D. Reduced sensory responses

Correct answer: B

Rationale: Fixed, dilated pupils are a sign of increased intracranial pressure or brain injury, indicating a potentially serious neurological condition. Flaccid paralysis, although concerning, may not always indicate immediate life-threatening issues. Diminished spinal reflexes and reduced sensory responses are important neurological assessments but are not as acutely concerning as fixed, dilated pupils in this context.

3. The nurse receives a report on an older adult client with middle stage dementia. What information suggests the nurse should do immediate follow-up rather than delegate care to the nursing assistant?

• A. Has had a change in respiratory rate with an increase of 2 breaths
• B. Has had a change in heart rate with an increase of 10 beats
• C. Was minimally responsive to voice and touch
• D. Has had a blood pressure change with a drop of 8 mmHg systolic

Correct answer: C

Rationale: A change in responsiveness, as indicated by being minimally responsive to voice and touch, suggests a potential acute issue that requires immediate nursing assessment and intervention rather than delegation. Changes in vital signs (choices A, B, D) can be important but do not always indicate an immediate need for nursing intervention compared to a change in responsiveness.

4. After administering a proton pump inhibitor, which action should the nurse take to evaluate the effectiveness of the medication?

• A. Monitor gastrointestinal pain
• B. Ask the client about pain levels
• C. Check the client's vital signs
• D. Assess for signs of bleeding

Correct answer: B

Rationale: The correct answer is to ask the client about pain levels. Proton pump inhibitors (PPIs) work by reducing stomach acid to alleviate gastrointestinal pain. By inquiring about the client's pain experience, the nurse can directly assess the effectiveness of the medication. Monitoring bowel movements (Choice A) is not directly related to evaluating the effectiveness of a PPI. Checking vital signs (Choice C) may not reflect the medication's effectiveness in reducing stomach acid. Assessing for signs of bleeding (Choice D) is important but not the most direct way to evaluate the effectiveness of a PPI.

5. A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which information is most important for the nurse to provide the parents prior to discharge?

• A. Nutritional guidelines to support blood health
• B. Signs of infection to monitor for
• C. When to give pain medication
• D. Instructions about how much fluid the child should drink daily

Correct answer: D

Rationale: Proper hydration is crucial in managing sickle cell anemia (SCA) as it helps prevent sickling of red blood cells and reduces blood viscosity, which can lead to painful crises. Ensuring the child drinks enough fluids is essential to maintain adequate hydration levels and reduce the risk of complications. While nutritional guidelines and recognizing signs of infection are important aspects of care, maintaining proper hydration is the most immediate and critical factor in managing SCA and preventing crises.

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