Nursing Elites

1. A client with peptic ulcer disease is being taught about lifestyle modifications by a nurse. Which client statement indicates a need for further teaching?

• A. ‘I should avoid drinking alcohol to prevent irritation of my ulcer.’
• B. ‘I should take my antacids regularly, even if I don’t have symptoms.’
• C. ‘I should avoid eating spicy foods to prevent irritation of my ulcer.’
• D. ‘I should limit my caffeine intake to prevent irritation of my ulcer.’

Correct answer: B

Rationale: The statement ‘I should take my antacids regularly, even if I don’t have symptoms’ indicates a misunderstanding. Antacids should only be taken when symptoms are present to neutralize excess stomach acid. Taking antacids regularly when not experiencing symptoms may lead to metabolic alkalosis. Choices A, C, and D are correct statements for a client with peptic ulcer disease as they all focus on avoiding irritants that can exacerbate the condition.

2. A nurse is preparing to administer a dose of digoxin (Lanoxin) to a client with heart failure. Which assessment finding requires immediate intervention?

• A. Apical pulse of 58 beats per minute
• B. Blood pressure of 110/70 mmHg
• C. Presence of a new murmur
• D. Respiratory rate of 18 breaths per minute

Correct answer: A

Rationale: An apical pulse of 58 beats per minute is concerning when administering digoxin because digoxin can further lower the heart rate, leading to bradycardia or heart block. Immediate intervention is required to prevent potential complications. A blood pressure of 110/70 mmHg is within normal range and does not require immediate intervention in this context. The presence of a new murmur may indicate valvular issues but does not directly relate to the administration of digoxin. A respiratory rate of 18 breaths per minute is also within normal limits and is not a priority concern when administering digoxin.

3. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which clinical finding requires immediate intervention?

• A. Oxygen saturation of 90%
• B. Respiratory rate of 24 breaths per minute
• C. Use of accessory muscles
• D. Inspiratory crackles

Correct answer: C

Rationale: The correct answer is C: Use of accessory muscles. In a client with COPD receiving supplemental oxygen, the use of accessory muscles is a critical finding that requires immediate intervention. This observation indicates increased work of breathing, suggesting respiratory distress. Addressing this issue promptly is crucial to prevent further respiratory compromise. Choice A, oxygen saturation of 90%, is slightly below the normal range but may not require immediate intervention unless it continues to decrease. Choice B, a respiratory rate of 24 breaths per minute, is within normal limits for an adult and does not indicate an urgent issue. Choice D, inspiratory crackles, may be present in COPD due to secretions or inflammation but do not necessitate immediate intervention unless associated with other concerning signs.

4. During a home visit, the nurse observed an elderly client with diabetes slip and fall. What action should the nurse take first?

• A. Give the client 4 ounces of orange juice
• B. Call 911 to summon emergency assistance
• C. Check the client for lacerations or fractures
• D. Assess client's blood sugar level

Correct answer: C

Rationale: The correct first action for the nurse to take after an elderly client with diabetes slips and falls is to check the client for lacerations or fractures. This is crucial to assess for any immediate physical injuries that may need immediate attention. Giving orange juice or assessing the blood sugar level may be important later but checking for injuries takes precedence to ensure the client's safety and well-being. Calling 911 should be considered if there are severe injuries or if the client is in distress, but checking for lacerations or fractures is the priority at the moment.

5. A client with liver cirrhosis is admitted with ascites and jaundice. Which assessment finding is most concerning?

• A. Serum albumin of 3.0 g/dL
• B. Bilirubin of 3.0 mg/dL
• C. Ammonia level of 80 mcg/dL
• D. Prothrombin time of 18 seconds

Correct answer: C

Rationale: An ammonia level of 80 mcg/dL is elevated and concerning in a client with liver cirrhosis, as it may indicate hepatic encephalopathy. Elevated ammonia levels can lead to cognitive impairment, altered mental status, and even coma. Serum albumin, bilirubin, and prothrombin time are also important markers in liver cirrhosis but are not as directly associated with the risk of hepatic encephalopathy as elevated ammonia levels.

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