Nursing Elites

1. A nurse is assessing a client who has been taking lithium for bipolar disorder. Which of the following findings should the nurse report to the provider?

• A. Tremors
• B. Increased thirst
• C. Weight gain
• D. Diarrhea

Correct answer: A

Rationale: Corrected Rationale: Tremors can indicate lithium toxicity, which should be reported to the provider for further evaluation. Tremors are a significant sign of lithium toxicity and can lead to serious complications if not addressed promptly. Increased thirst, weight gain, and diarrhea are common side effects of lithium but are not typically indicative of toxicity. Therefore, the nurse should prioritize reporting tremors as it requires immediate attention.

2. A nurse is caring for a client who is 12 hr postpartum and has a third-degree perineal laceration. The client reports not having a bowel movement for 4 days. Which of the following medications should the nurse administer?

• A. Bisacodyl 10 mg rectal suppository.
• B. Magnesium hydroxide 30 ml PO.
• C. Famotidine 20 mg PO.
• D. Loperamide 4 mg PO.

Correct answer: A

Rationale: In this scenario, the nurse should administer Bisacodyl 10 mg rectal suppository. Bisacodyl is a stimulant laxative that promotes bowel movement, which is appropriate for a postpartum client experiencing constipation. Magnesium hydroxide (choice B) is an antacid and not indicated for constipation. Famotidine (choice C) is an H2 receptor antagonist used for reducing stomach acid production, not for constipation. Loperamide (choice D) is an antidiarrheal agent and would worsen constipation in this case.

3. A nurse is planning care for a school-age child who is 4 hours postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care?

• A. Offer small amounts of clear liquids 6 hours following surgery.
• B. Give cromolyn nebulizer solution every 6 hours.
• C. Apply a warm compress to the operative site every 4 hours.
• D. Administer analgesics on a scheduled basis for the first 24 hours.

Correct answer: D

Rationale: Administering analgesics on a scheduled basis for the first 24 hours is crucial in managing postoperative pain for the child. This helps control pain levels effectively, promoting comfort and aiding in the recovery process. Offering small amounts of clear liquids 6 hours following surgery may not be appropriate as the child may need time to recover from anesthesia. Giving cromolyn nebulizer solution every 6 hours is not indicated for postoperative care following appendicitis surgery. Applying a warm compress every 4 hours to the operative site may not be recommended as it can potentially interfere with the surgical wound healing process.

4. When digitally evacuating stool from a client with a fecal impaction, what action should the nurse take?

• A. Insert a lubricated gloved finger and advance along the rectal wall
• B. Apply lubricant and stimulate peristalsis
• C. Apply pressure to the abdomen to assist with removal
• D. Increase fluid intake before the procedure

Correct answer: A

Rationale: The correct action when digitally evacuating stool from a client with a fecal impaction is to insert a lubricated gloved finger and advance along the rectal wall. This technique helps prevent trauma to the client. Choice B is incorrect because stimulating peristalsis is not the appropriate action for digitally evacuating stool. Choice C is incorrect as applying pressure to the abdomen can be uncomfortable and ineffective. Choice D is also incorrect because increasing fluid intake is not directly related to the digital evacuation procedure.

5. A nurse is caring for a client who is in the orientation phase of the therapeutic relationship. Which statement should the nurse make during this phase?

• A. Let's talk about how you can change your response to stress.
• B. We should establish our roles in the initial session.
• C. Let me show you simple relaxation exercises to manage stress.
• D. We should discuss resources to implement in your daily life.

Correct answer: B

Rationale: During the orientation phase of the therapeutic relationship, it is crucial to establish roles. This helps both the client and the nurse understand their responsibilities, boundaries, and expectations within the therapeutic process. Choice A is more focused on the working phase where strategies and interventions are discussed. Choice C is more suitable for the working phase where specific techniques are usually introduced. Choice D is also more relevant to the working phase as it involves discussing practical resources for implementation in daily life.

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