Nursing Elites

1. A client with intestinal obstructions has a nasogastric tube to low intermittent suction and is receiving an IV of lactated Ringer’s at 100 ml/H. Which finding is most important for the nurse to report to the healthcare provider?

• A. Gastric output of 900 mL in the last 24 hours
• B. Serum potassium level of 3.1 mEq/L or mmol/L (SI)
• C. Increased blood urea nitrogen (BUN)
• D. 24-hour intake at the current infusion rate

Correct answer: B

Rationale: The most crucial finding to report to the healthcare provider in this scenario is a serum potassium level of 3.1 mEq/L. Hypokalemia can lead to serious complications, including cardiac issues. Gastric output, increased BUN, and monitoring the 24-hour intake are essential but do not pose an immediate risk as hypokalemia does in this situation.

2. A high school football player comes to the clinic complaining of severe acne. The mother reports recent behavior changes, including irritability and suspiciousness of friends. The nurse’s assessment reveals an elevated blood pressure. Which intervention should the nurse implement first?

• A. Encourage the client to see a dermatologist
• B. Refer the adolescent to a substance abuse program
• C. Suggest a low-salt, low-fat, and caffeine-free diet
• D. Inquire about a possible use of anabolic steroids

Correct answer: D

Rationale: In this scenario, the high school football player presenting with severe acne, behavior changes, elevated blood pressure, and suspicion of friends suggests the possible use of anabolic steroids. Anabolic steroid use can lead to such symptoms. Therefore, the nurse should first inquire about the possible use of anabolic steroids to address the root cause of the presenting issues. Encouraging the client to see a dermatologist (Choice A) may be necessary but addressing the underlying cause is crucial first. Referring the adolescent to a substance abuse program (Choice B) is premature without confirming steroid use. Suggesting a low-salt, low-fat, and caffeine-free diet (Choice C) is not the priority in this situation where a serious issue like anabolic steroid use needs immediate attention.

3. For a client with pneumonia, the prescription states, “Oxygen at liters/min per nasal cannula PRN difficult breathing.” Which nursing intervention is effective in preventing oxygen toxicity?

• A. Avoiding the administration of oxygen at high levels for extended periods.
• B. Administering a sedative at bedtime to slow the client’s respiratory rate.
• C. Removing the nasal cannula during the night to prevent oxygen buildup.
• D. Running oxygen through a hydration source prior to administration.

Correct answer: A

Rationale: Choice A is the correct answer because prolonged exposure to high levels of oxygen can lead to oxygen toxicity. Administering oxygen at high levels for extended periods can overwhelm the body's natural defenses against high oxygen levels, causing toxicity. Choices B, C, and D are incorrect. Choice B is unrelated to preventing oxygen toxicity. Choice C is unsafe as removing the nasal cannula can deprive the client of necessary oxygen. Choice D, running oxygen through a hydration source, is not a standard practice for preventing oxygen toxicity.

4. To reduce the risk of symptoms exacerbation for a client with multiple sclerosis (MS), which instructions should the nurse include in the client’s discharge plan? (Select all that apply).

• A. Practice relaxation exercises
• B. Limit fluids to avoid bladder distention
• C. Space activities to allow for rest periods
• D. Avoid persons with infections

Correct answer: A

Rationale: The correct instruction to include in the discharge plan for a client with MS to reduce symptom exacerbation is practicing relaxation exercises. Relaxation exercises can help manage MS symptoms by reducing stress. Limiting fluids to avoid bladder distention is not appropriate as adequate hydration is essential for overall health and helps prevent complications like urinary tract infections. While spacing activities to allow for rest periods can be beneficial for general well-being, it is not directly related to symptom exacerbation in MS. Avoiding persons with infections is important to prevent infections, but it is not specifically targeted at reducing MS symptom exacerbation.

5. A 37-year-old client diagnosed with chronic kidney disease (CKD) is being treated for renal osteodystrophy. Which nursing diagnosis is most likely to be included in this client’s plan of care?

• A. High risk for infection related to subclavian catheter
• B. High risk of injury related to ambulation
• C. Knowledge deficit related to a high-protein diet
• D. Hygiene self-care deficit related to uremic frost

Correct answer: D

Rationale: The correct answer is D. Uremic frost is a condition in which urea and other waste products are excreted through the skin, leaving a powdery residue. This indicates poor hygiene and self-care, common issues in patients with CKD and renal osteodystrophy. Proper hygiene measures are essential to prevent complications. Choices A, B, and C are less likely to be included in the plan of care for a CKD patient with renal osteodystrophy. Choice A is more related to a vascular access issue, choice B is more related to mobility concerns, and choice C is more related to dietary education.

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