Nursing Elites

1. A client is experiencing diarrhea. For which acid-base disorder should the nurse assess the client?

• A. Metabolic acidosis
• B. Metabolic alkalosis
• C. Respiratory acidosis
• D. Respiratory alkalosis

Correct answer: A

Rationale: When a client experiences diarrhea, the loss of bicarbonate-rich fluids from the body leads to a decrease in the bicarbonate levels in the blood, resulting in metabolic acidosis. Metabolic alkalosis (choice B) is characterized by an increase in bicarbonate levels, which is not typically associated with diarrhea. Respiratory acidosis (choice C) is caused by retention of carbon dioxide, while respiratory alkalosis (choice D) results from excessive exhalation of carbon dioxide, neither of which are directly related to diarrhea. Therefore, the correct answer is metabolic acidosis (choice A) in the context of diarrhea.

2. The nurse is providing teaching to a patient who will begin taking a cephalosporin to treat an infection. Which statement by the patient indicates a need for further teaching?

• A. I may stop taking the medication if my symptoms clear up.
• B. I should eat yogurt while taking this medication.
• C. I should stop taking the drug and call my provider if I develop a rash.
• D. I will not consume alcohol while taking this medication.

Correct answer: A

Rationale: Patients should take all of an antibiotic regimen even after symptoms clear to ensure complete treatment of the infection.

3. A client with nephrotic syndrome is being assessed by a nurse. For which clinical manifestations should the nurse assess? (Select all that apply.)

• A. Proteinuria
• B. Hypoalbuminemia
• C. Lipiduria
• D. All of the above

Correct answer: D

Rationale: Nephrotic syndrome is characterized by glomerular damage, leading to proteinuria (excessive protein in the urine), hypoalbuminemia (low levels of albumin in the blood), and lipiduria (lipids in the urine). These manifestations are key indicators of nephrotic syndrome. Edema, often severe, is also common due to decreased plasma oncotic pressure from hypoalbuminemia. The correct answer is 'All of the above' because all three manifestations are associated with nephrotic syndrome. Dehydration is not a typical finding in nephrotic syndrome as it is more commonly associated with fluid retention and edema. Dysuria is a symptom of cystitis, not nephrotic syndrome. CVA tenderness is more indicative of inflammatory changes in the kidney rather than nephrotic syndrome.

4. The healthcare provider notes a blood pressure of 160/90 mm Hg in a patient taking a thiazide diuretic. The patient reports taking an herbal medication that a friend recommended. Which herbal product is likely, given this patient’s blood pressure?

• A. Ginkgo
• B. Hawthorn
• C. Licorice
• D. St. John’s wort

Correct answer: A

Rationale: The correct answer is A: Ginkgo. Increased blood pressure can result when ginkgo is used in combination with a thiazide diuretic. Option B (Hawthorn) is incorrect because hawthorn is more commonly associated with lowering blood pressure. Option C (Licorice) is incorrect because licorice can lead to sodium and water retention, potentially exacerbating hypertension. Option D (St. John’s wort) is incorrect as it is not typically associated with significant blood pressure effects.

5. When working with a large population of African-American clients at a community health center, which priority assessment should a nurse include?

• A. Measure height and weight.
• B. Assess blood pressure.
• C. Observe for any signs of abuse.
• D. Ask about medications.

Correct answer: B

Rationale: Assessing blood pressure is the priority assessment when working with a population of African-American clients due to the high prevalence of hypertension in this group. African Americans have a higher risk of hypertension, which can lead to complications like end-stage renal disease. Monitoring blood pressure allows for the early detection and management of hypertension. While measuring height and weight, observing for signs of abuse, and asking about medications are important assessments, assessing blood pressure is crucial in this context to address the specific health needs of African-American clients.

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