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. The nurse is caring for a client with a suspected myocardial infarction (MI). Which laboratory test result is most indicative of a recent MI?

• A. Elevated troponin levels
• B. Increased white blood cell count
• C. Increased lactate dehydrogenase (LDH)
• D. Elevated C-reactive protein (CRP)

Correct answer: A

Rationale: Elevated troponin levels are the most specific and sensitive indicator of myocardial infarction. Troponin levels increase within hours of an MI and remain elevated for several days. White blood cell count, lactate dehydrogenase (LDH), and C-reactive protein (CRP) are not specific markers for MI. An increased white blood cell count may indicate inflammation or infection, increased LDH levels can be seen in various conditions like liver disease or muscle injury, and elevated CRP is a general marker of inflammation rather than specific to MI.

3. The healthcare provider is assessing a client who has just received anesthesia. What is the most critical finding to report to the healthcare provider?

• A. Client reports dizziness
• B. Client has a drop in blood pressure
• C. Client experiences mild nausea
• D. Client reports dry mouth

Correct answer: B

Rationale: A significant drop in blood pressure following anesthesia could indicate a serious reaction, such as hypovolemia or anesthetic-induced hypotension. This requires immediate medical attention, while other symptoms like dizziness, mild nausea, and dry mouth are more common and less critical. Dizziness could be expected due to the effects of anesthesia, mild nausea is a common side effect, and dry mouth is a known effect of anesthesia as well.

4. A client in the third trimester of pregnancy reports that she feels some 'lumpy places' in her breasts and that her nipples sometimes leak a yellowish fluid. She has an appointment with her healthcare provider in two weeks. What action should the nurse take?

• A. Instruct the client to immediately see her provider for an evaluation
• B. Assess the fluid for signs of infection
• C. Explain that this normal secretion can be assessed at the next visit
• D. Recommend breast ultrasound to rule out abnormalities

Correct answer: C

Rationale: The yellowish fluid is likely colostrum, a normal finding in late pregnancy as the breasts prepare for lactation. It is common for women in the third trimester to experience 'lumpy places' in the breasts due to increased milk duct development. In this situation, the nurse should educate the client that these findings are normal physiological changes associated with pregnancy. Since the client has an upcoming appointment with her healthcare provider in two weeks, it is appropriate to reassure her that this can be further assessed during that visit. Instructing the client to immediately see her provider (Choice A) is unnecessary as this is a common finding in late pregnancy. Assessing the fluid for signs of infection (Choice B) is not warranted as colostrum leakage is a normal occurrence. Recommending a breast ultrasound (Choice D) is premature without further assessment by the healthcare provider.

5. The father of a 4-year-old has been battling metastatic lung cancer for the past 2 years. After discussing the remaining options with his healthcare provider, the client requests that all treatment stop and that no heroic measures be taken to save his life. When the client is transferred to the palliative care unit, which action is most important for the nurse working on the palliative care unit to take in facilitating continuity of care?

• A. Ensure the client's family is aware of the client's wishes
• B. Begin comfort measures immediately
• C. Obtain a detailed report from the nurse transferring the client
• D. Confirm that the client understands the treatment plan

Correct answer: C

Rationale: Obtaining a detailed report from the previous nurse ensures continuity of care and that all relevant information is passed on. This is critical in palliative care, where comfort measures and symptom management are key components of care. Choice A is not the most important action in this scenario, as the question focuses on continuity of care within the healthcare team. Beginning comfort measures immediately, as in choice B, is essential but obtaining a detailed report takes precedence to ensure a smooth transition of care. Confirming that the client understands the treatment plan, as in choice D, is important but does not directly address the need for continuity of care through a detailed report.

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