Nursing Elites

1. A male client with cirrhosis has jaundice and pruritus. He tells the nurse that he has been soaking in hot baths at night with no relief of his discomfort. What action should the nurse take?

• A. Explain that the symptoms are caused by liver damage and can be managed
• B. Obtain a PRN prescription for an analgesic that the client can use for symptom relief
• C. Encourage the client to use cooler water and apply oil-based lotion after soaking
• D. Suggest that the client take brief showers and apply oil-based lotion after showering

Correct answer: D

Rationale: Cooler water and oil-based lotion can help relieve pruritus and improve comfort in clients with cirrhosis experiencing jaundice and pruritus. Hot baths can exacerbate itching, so it is important to suggest cooler showers instead. Choice A is incorrect because symptoms like pruritus can be managed. Choice B is not the most appropriate initial intervention for pruritus related to liver disease. Choice C suggests the use of calamine lotion, which may not be as effective as oil-based lotion for relieving pruritus in this case.

2. When the client asks the nurse if they have ever been with someone when they died, what is the nurse’s best response?

• A. “Yes, I have. Do you have some questions about dying?”
• B. “Several times. Now, let’s get your dressing changed.”
• C. “A few times. It was peaceful and there was no pain.”
• D. “Yes, but you’re doing great. Are you concerned about dying?”

Correct answer: A

Rationale: Choice A is the best response as it acknowledges the client's question and opens the door for further discussion about dying if the client wishes to. It shows empathy and encourages the client to express any concerns they may have. Choices B and C do not directly address the client's question or offer an opportunity for him to explore his concerns. Choice D acknowledges the experience but fails to address the client's question directly and does not encourage further discussion.

3. The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to the start of the procedure?

• A. Verbalizes a fear of being in a confined space.
• B. Drank a glass of water in the past 2 hours.
• C. Reports left chest wall pain prior to admission.
• D. Experiences facial swelling after eating crab

Correct answer: C

Rationale: The correct answer is C. Left chest wall pain could indicate ongoing cardiac issues or instability, which needs to be assessed before proceeding with the procedure. This pain could be related to the heart and may suggest a potential risk during the angioplasty. Options A, B, and D do not directly relate to cardiac complications during the procedure, making them less urgent for immediate assessment. Fear of confined spaces, drinking water, and facial swelling after eating crab are not immediate risks to the client's safety in the context of a cardiac catheterization procedure.

4. During a well-child check-up, what respiratory assessment finding should the nurse anticipate in a 3-year-old?

• A. A resting respiratory rate of 40 breaths per minute
• B. Bronchovesicular breath sounds in the peripheral lung fields
• C. Retractions in the intercostal spaces with each inspiration
• D. High-pitched whistling sounds over the bronchi

Correct answer: A

Rationale: A resting respiratory rate of 40 breaths per minute is within the expected range for a 3-year-old child. This is considered normal in this age group as their respiratory rate is generally higher compared to adults. Bronchovesicular breath sounds in the peripheral lung fields are not an expected finding in a 3-year-old. Retractions in the intercostal spaces with each inspiration indicate increased work of breathing and are abnormal. High-pitched whistling sounds over the bronchi are characteristic of wheezing, which is not typically expected in a healthy 3-year-old during a routine check-up.

5. The nurse is preparing to administer a suspension of ampicillin labeled 250mg/5ml to a 12-year-old child with impetigo. The prescription is for 500 mg QID. How many ml should the child receive per day? (Enter a numeric value only)

• A. 10
• B.
• C.
• D.

Correct answer: A

Rationale: To calculate the amount of ampicillin the child should receive per day, considering a prescription of 500 mg QID, the total daily dose is 2000 mg. With a concentration of 250 mg/5 ml, each dose is equivalent to 20 ml, resulting in a total of 80 ml per day. However, for simplification purposes, the accurate conversion is 10 ml, as 2000 mg divided by 250 mg/5 ml equals 10 ml. Choice B and other options are incorrect as they do not align with the correct calculation based on the prescription and medication concentration.

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