Nursing Elites

1. A nurse is caring for a client who has a fecal impaction. Which action should the nurse take when digitally evacuating the stool?

• 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 a fecal impaction is to insert a lubricated gloved finger and advance along the rectal wall. This technique helps prevent trauma and effectively dislodge the impacted stool. Choice B, applying lubricant and stimulating peristalsis, is incorrect as it does not directly address the evacuation of the impacted stool. Choice C, applying pressure to the abdomen, is inappropriate and may cause discomfort or harm to the client. Choice D, increasing fluid intake before the procedure, is not directly related to the immediate evacuation of the fecal impaction.

2. A client with heart failure is receiving a continuous IV infusion of milrinone. Which of the following actions should the nurse take?

• A. Monitor the client's blood pressure continuously
• B. Weigh the client daily
• C. Monitor the infusion site for signs of infiltration
• D. Measure the client's intake and output every 2 hours

Correct answer: D

Rationale: Measuring the client's intake and output every 2 hours is essential when caring for a client receiving a continuous IV infusion of milrinone. Milrinone is a medication that affects fluid balance, and monitoring intake and output helps assess the client's response to the medication. Continuous monitoring of blood pressure may not be necessary unless there is a specific indication. While weighing the client daily is important for overall assessment, measuring intake and output more frequently provides more real-time data for fluid balance evaluation. Monitoring the infusion site is crucial for detecting infiltration but is not directly related to managing fluid balance in this situation.

3. A client with Parkinson's disease is receiving physical therapy. Which statement by the client indicates the need for a referral to physical therapy?

• A. I have been experiencing more tremors in my left arm than before
• B. I noticed that I am having a harder time holding onto my toothbrush
• C. Lately, I feel like my feet are freezing up, as they are stuck to the ground
• D. Sometimes, I feel I am making a chewing motion when I'm not eating

Correct answer: C

Rationale: The correct answer is C because freezing of feet while walking is a sign of impaired mobility, indicating the need for physical therapy in clients with Parkinson's disease. Choices A, B, and D are symptoms commonly associated with Parkinson's disease but do not specifically indicate the need for immediate referral to physical therapy.

4. While reviewing the monitor tracing of a client in labor, a nurse notes late decelerations. Which of the following interventions should the nurse perform?

• A. Administer oxygen via nasal cannula
• B. Reposition the client onto her left side
• C. Administer an amnioinfusion
• D. Provide reassurance to the client

Correct answer: B

Rationale: Repositioning the client onto her left side is the appropriate intervention when late decelerations are noted on the monitor tracing. This action helps increase uteroplacental blood flow by relieving pressure on the vena cava and aorta, improving fetal oxygenation. Administering oxygen via nasal cannula may be indicated for variable decelerations, not late decelerations. Administering an amnioinfusion is not the primary intervention for late decelerations. Providing reassurance to the client is important but addressing the underlying cause of late decelerations takes precedence.

5. Which electrolyte imbalance is most concerning in a patient on furosemide?

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

Correct answer: B

Rationale: The correct answer is Hypokalemia. Furosemide is a loop diuretic that can lead to potassium depletion by increasing its excretion in the urine. Hypokalemia is a common and concerning side effect of furosemide therapy. Hyperkalemia (Choice A) is less likely as furosemide tends to lower potassium levels. Hyponatremia (Choice C) is more commonly seen with thiazide diuretics. Hypercalcemia (Choice D) is not directly associated with furosemide use.

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