Nursing Elites

1. A client with liver cirrhosis is receiving lactulose for hepatic encephalopathy. Which finding indicates the medication is effective?

• A. The client's level of consciousness improves.
• B. The client's ammonia level decreases.
• C. The client has three bowel movements daily.
• D. The client's liver enzymes return to normal.

Correct answer: B

Rationale: The correct answer is B: "The client's ammonia level decreases." In hepatic encephalopathy, elevated ammonia levels contribute to neurological symptoms. Lactulose works by promoting the excretion of ammonia in the stool, leading to decreased serum ammonia levels. Therefore, a decrease in ammonia levels indicates that lactulose is effectively reducing ammonia buildup, improving hepatic encephalopathy symptoms. Choices A, C, and D are incorrect because improvement in level of consciousness, bowel movements, or normalization of liver enzymes may not directly reflect the effectiveness of lactulose in reducing ammonia levels and improving hepatic encephalopathy.

2. During a thyroid storm, what is the nurse's priority intervention for a client experiencing increased heart rate and tremors?

• A. Administer antithyroid medications as prescribed.
• B. Administer a beta-blocker to control the heart rate.
• C. Monitor the client's temperature closely.
• D. Prepare the client for an emergency thyroidectomy.

Correct answer: A

Rationale: The correct answer is to administer antithyroid medications as prescribed during a thyroid storm. Antithyroid medications help control the overproduction of thyroid hormones, which is crucial in managing symptoms such as increased heart rate and tremors. These symptoms can be life-threatening if not promptly addressed. Administering a beta-blocker (Choice B) may help control the heart rate, but addressing the underlying cause with antithyroid medications is the priority. Monitoring the client's temperature (Choice C) is important but not the priority intervention during a thyroid storm. Lastly, preparing the client for an emergency thyroidectomy (Choice D) is not the initial intervention for managing symptoms of a thyroid storm.

3. A client with hyperthyroidism is experiencing palpitations. What intervention should the nurse implement?

• A. Encourage the client to rest and limit activity.
• B. Administer a beta-blocker to reduce heart rate.
• C. Encourage the client to drink cool fluids.
• D. Provide the client with a cool environment.

Correct answer: B

Rationale: In clients with hyperthyroidism experiencing palpitations, administering a beta-blocker is the appropriate intervention. Beta-blockers help reduce heart rate and control symptoms in hyperthyroidism. Encouraging rest (Choice A) may be helpful but does not directly address the palpitations. Drinking cool fluids (Choice C) and providing a cool environment (Choice D) are more focused on temperature regulation and comfort, which are not the primary interventions for palpitations in hyperthyroidism.

4. A client is admitted with ascites, malnutrition, and recent complaints of spitting up blood. What assessment finding warrants immediate intervention by the nurse?

• A. Capillary refill of 8 seconds
• B. Bruises on arms and legs
• C. Round and tight abdomen
• D. Pitting edema in lower legs

Correct answer: C

Rationale: A round and tight abdomen suggests fluid accumulation from ascites, which could signal a more severe underlying condition requiring immediate intervention. This finding indicates increased intra-abdominal pressure, which can lead to respiratory compromise or other serious complications. Capillary refill time, bruises on arms and legs, and pitting edema in the lower legs are important assessments but do not directly indicate the need for immediate intervention as a round and tight abdomen does in this case.

5. A client with hypocalcemia is receiving calcium gluconate. What assessment finding requires immediate intervention?

• A. Decreased deep tendon reflexes.
• B. Wheezing and stridor.
• C. Decreased bowel sounds.
• D. Positive Chvostek's sign.

Correct answer: B

Rationale: Wheezing and stridor may indicate a severe allergic reaction to calcium gluconate, such as anaphylaxis, which requires immediate intervention. While hypocalcemia can present with decreased deep tendon reflexes and positive Chvostek's sign, these findings do not indicate an immediate life-threatening situation. Decreased bowel sounds are not directly related to a severe reaction to calcium gluconate and do not require immediate intervention.

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