Nursing Elites

1. A client with pancreatitis reports severe pain after eating fatty foods. What intervention should the nurse implement?

• A. Encourage the client to eat small, low-fat meals.
• B. Administer antispasmodic medication as prescribed.
• C. Instruct the client to avoid eating until the pain subsides.
• D. Increase the client’s intake of high-protein foods.

Correct answer: B

Rationale: In pancreatitis, pain after consuming fatty foods is common due to increased pancreatic stimulation. Administering antispasmodics is the appropriate intervention as it can help reduce the pain by decreasing pancreatic enzyme secretion. Encouraging the client to eat small, low-fat meals (Choice A) is beneficial in managing pancreatitis symptoms but does not directly address the acute pain. Instructing the client to avoid eating until the pain subsides (Choice C) may lead to nutritional deficiencies and is not the best approach. Increasing high-protein foods intake (Choice D) is not recommended as it can put additional strain on the pancreas.

2. When monitoring tissue perfusion following an above the knee amputation (AKA), which action should the nurse include in the plan of care?

• A. Evaluate the closest proximal pulse.
• B. Observe the color and amount of wound drainage.
• C. Observe for swelling around the stump.
• D. Assess the skin elasticity of the stump.

Correct answer: A

Rationale: Evaluating the closest proximal pulse is essential when monitoring tissue perfusion post-amputation. This pulse provides crucial information about the circulation and perfusion to the limb. Observing the color and amount of wound drainage (Choice B) is more related to wound healing assessment rather than tissue perfusion. Observing for swelling around the stump (Choice C) may indicate inflammation or infection but is not the most direct assessment of tissue perfusion. Assessing skin elasticity of the stump (Choice D) is important for skin integrity but does not directly reflect tissue perfusion.

3. A client with advanced chronic kidney disease (CKD) is scheduled for hemodialysis. Which dietary instruction should the nurse provide to the client?

• A. Limit fluid intake to prevent fluid overload
• B. Increase sodium intake to improve fluid balance
• C. Increase potassium intake to prevent hypokalemia
• D. Increase protein intake to promote healing

Correct answer: A

Rationale: The correct answer is A: 'Limit fluid intake to prevent fluid overload.' Clients with advanced chronic kidney disease are at risk of fluid retention, which can lead to complications like fluid overload and hypertension. Therefore, it is crucial to instruct the client to limit fluid intake. Choice B is incorrect because increasing sodium intake can exacerbate fluid retention and hypertension in clients with CKD. Choice C is incorrect as increasing potassium intake can be dangerous for clients with CKD who may already have elevated potassium levels. Choice D is incorrect because while protein intake may need to be adjusted for clients on hemodialysis, the priority in this case is managing fluid intake.

4. A client presents to the emergency department with a severe exacerbation of asthma. The nurse notes that the client is using accessory muscles to breathe and has an oxygen saturation of 86%. Which intervention should the nurse implement first?

• A. Place the client in a high-Fowler's position
• B. Obtain a peak flow reading
• C. Administer a bronchodilator
• D. Administer oxygen therapy

Correct answer: D

Rationale: The first priority in an acute asthma exacerbation is to administer oxygen to improve the client's oxygen saturation. In this scenario, the client has a low oxygen saturation level of 86%, indicating hypoxemia, which can be life-threatening. Administering oxygen therapy will help improve oxygenation and support vital organ function. Once the oxygen levels are stabilized, further interventions such as bronchodilators can be implemented. Placing the client in a high-Fowler's position may also be beneficial, but ensuring adequate oxygenation takes precedence in this critical situation. Obtaining a peak flow reading is important for asthma management but is not the first intervention needed in a client with severe hypoxemia.

5. A client with hyperparathyroidism is preparing for surgery. Which preoperative lab finding is most important to report?

• A. Elevated serum calcium.
• B. Decreased serum albumin.
• C. Elevated serum potassium.
• D. Elevated serum magnesium.

Correct answer: A

Rationale: The correct answer is A: Elevated serum calcium. In hyperparathyroidism, elevated calcium levels can lead to complications such as kidney stones, bone pain, and fractures. During surgery, high calcium levels can affect neuromuscular function, cardiac function, and blood clotting. Therefore, it is crucial to report elevated serum calcium levels preoperatively to prevent potential surgical complications. Choices B, C, and D are not directly associated with hyperparathyroidism and are less likely to impact the surgical outcome in this scenario.

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