Nursing Elites

1. A nurse is assessing a client who has cirrhosis. Which of the following findings should the nurse expect?

• A. Clay-colored stools.
• B. Hypertension.
• C. Stridor.
• D. Elevated temperature.

Correct answer: A

Rationale: Clay-colored stools are a classic finding in a client with cirrhosis. Cirrhosis can lead to impaired bile flow, resulting in pale or clay-colored stools due to a lack of bilirubin in the stool. Hypertension, stridor, and elevated temperature are not typically associated with cirrhosis. Hypertension may occur in cirrhosis but is not a consistent finding, stridor is more commonly associated with upper airway obstruction, and elevated temperature may indicate an infection rather than a direct result of cirrhosis.

2. Which electrolyte imbalance is a common concern for patients on loop diuretics?

• A. Hypokalemia
• B. Hyperkalemia
• C. Hyponatremia
• D. Hypercalcemia

Correct answer: A

Rationale: The correct answer is A, Hypokalemia. Loop diuretics can lead to potassium loss, resulting in hypokalemia. This imbalance is a common concern because potassium plays a vital role in various physiological functions, including maintaining proper heart function. Choices B, C, and D are incorrect because loop diuretics typically do not cause hyperkalemia, hyponatremia, or hypercalcemia.

3. A healthcare provider is assessing a client who has pneumonia. Which of the following findings is the priority for the healthcare provider to report?

• A. Crackles in the lung bases
• B. Blood pressure of 100/64 mm Hg
• C. Respiratory rate of 26/min
• D. Heart rate of 86/min

Correct answer: C

Rationale: A respiratory rate of 26/min is a sign of respiratory distress and should be reported promptly in a client with pneumonia. Rapid breathing can indicate inadequate oxygenation and ventilation, which may lead to respiratory failure. Crackles in the lung bases are common in pneumonia but may not be as urgent as a high respiratory rate. A blood pressure of 100/64 mm Hg is slightly low but may not be immediately life-threatening. A heart rate of 86/min is within the normal range for an adult and is not the most critical finding to report.

4. A client with a new diagnosis of Crohn's disease is being taught about dietary management by a nurse. Which of the following instructions should the nurse include?

• A. Eat foods that are high in fiber.
• B. Avoid dairy products to reduce diarrhea.
• C. Eat small, frequent meals to reduce symptoms.
• D. You should increase your intake of whole grains.

Correct answer: C

Rationale: The correct instruction the nurse should include is to advise the client to eat small, frequent meals to reduce symptoms of Crohn's disease. This eating pattern can help manage symptoms by reducing the workload on the digestive system. Choice A is incorrect because foods high in fiber can aggravate symptoms in Crohn's disease. Choice B is incorrect because not all individuals with Crohn's disease need to avoid dairy products, and it is not a universal recommendation. Choice D is incorrect because increasing whole grains may not be suitable for everyone with Crohn's disease, as it can worsen symptoms in some cases.

5. What is the initial nursing action for a patient presenting with chest pain?

• A. Administer aspirin
• B. Reposition the patient
• C. Provide pain relief
• D. Prepare for surgery

Correct answer: A

Rationale: The correct initial nursing action for a patient presenting with chest pain is to administer aspirin. Aspirin helps reduce the risk of further clot formation in patients experiencing chest pain, as it has antiplatelet effects. Repositioning the patient, providing pain relief, or preparing for surgery are not the first-line interventions for chest pain. Repositioning the patient may be necessary to ensure comfort and safety, pain relief can be provided after further assessment and diagnostic tests, and preparing for surgery would only be considered after a thorough evaluation and confirmation of the need for surgical intervention.

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