Nursing Elites

1. A female client reports that she drank a liter of a solution to cleanse her intestines but vomited immediately after. How many ml of fluid intake should the nurse document?

• A. 1000 ml
• B. 800 ml
• C. 760 ml
• D. 500 ml

Correct answer: C

Rationale: The correct answer is 760 ml. One liter equals 1000 ml. As the client vomited immediately after drinking, she would have expelled approximately 240 ml (1 cup). Subtracting this from the initial intake of 1000 ml gives us 760 ml as the remaining fluid intake that should be documented. Choices A, B, and D are incorrect because they do not reflect the correct calculation of subtracting the amount vomited from the initial intake.

2. A client with cirrhosis is admitted with jaundice and ascites. Which assessment finding requires immediate intervention?

• A. Peripheral edema
• B. Confusion and altered mental status
• C. Yellowing of the skin
• D. Increased abdominal girth

Correct answer: B

Rationale: Confusion and altered mental status are the most critical assessment findings in a client with cirrhosis. These symptoms may indicate hepatic encephalopathy, a serious complication that requires immediate intervention. Yellowing of the skin (jaundice) is a common manifestation of cirrhosis and does not necessitate immediate intervention. Peripheral edema and increased abdominal girth are associated with fluid retention in cirrhosis but are not as urgent as addressing altered mental status and confusion.

3. A client with a history of atrial fibrillation is admitted with a new onset of confusion. Which intervention should the nurse implement first?

• A. Obtain a blood glucose level.
• B. Administer an anticoagulant as prescribed.
• C. Perform a neurological assessment.
• D. Administer aspirin as prescribed.

Correct answer: C

Rationale: Performing a neurological assessment is the priority in this situation as it helps in evaluating the cause of the new onset of confusion in a client with atrial fibrillation. This assessment will provide crucial information about the client's neurological status, which can guide further interventions. Obtaining a blood glucose level (Choice A) is important but should not be the first step when dealing with a new onset of confusion. Administering an anticoagulant (Choice B) or aspirin (Choice D) may be necessary depending on the underlying cause, but assessing the neurological status comes first to determine the appropriate course of action.

4. A male client with hypertension, who received new antihypertensive prescriptions at his last visit, returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106, and he admits that he has not been taking the prescribed medication because the drugs make him 'feel bad'. In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition?

• A. Blindness due to cataracts
• B. Acute kidney injury due to glomerular damage
• C. Stroke secondary to hemorrhage
• D. Heart block due to myocardial damage

Correct answer: C

Rationale: The correct answer is C, 'Stroke secondary to hemorrhage.' Uncontrolled hypertension can lead to the weakening of blood vessels in the brain, increasing the risk of a stroke due to hemorrhage. This can result in serious neurological deficits or even death. Choices A, B, and D are incorrect because while hypertension can have various complications including vision changes, kidney damage, and heart problems, the most immediate and severe risk associated with uncontrolled hypertension is a stroke from cerebral hemorrhage.

5. A client is receiving continuous bladder irrigation via a triple-lumen suprapubic catheter that was placed during a prostatectomy. Which report by the unlicensed assistive personnel (UAP) requires intervention by the nurse?

• A. Leakage around the catheter insertion site.
• B. Pink-tinged urine in the drainage bag.
• C. Client reports discomfort at the catheter site.
• D. Decreased urine output in the last hour.

Correct answer: A

Rationale: The correct answer is A. Leakage around the catheter insertion site may indicate a problem with the catheter placement or function, requiring immediate intervention. Pink-tinged urine in the drainage bag is expected due to the continuous bladder irrigation. Discomfort at the catheter site is common after the procedure. Decreased urine output in the last hour may be due to the continuous bladder irrigation and doesn't require immediate intervention.

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