Nursing Elites

1. A patient with cirrhosis of the liver and ascites is scheduled for a paracentesis. What should the nurse do to prepare the patient for the procedure?

• A. Have the patient void immediately before the procedure.
• B. Position the patient upright or semi-Fowler's in bed.
• C. Administer a full liquid diet.
• D. Encourage the patient to ambulate for 30 minutes.

Correct answer: A

Rationale: The correct preparation for a paracentesis in a patient with cirrhosis and ascites includes having the patient void immediately before the procedure. This is important to reduce the risk of bladder puncture during the paracentesis. Positioning for a paracentesis is typically upright or semi-Fowler's, not flat in bed. Administering a full liquid diet or encouraging ambulation for 30 minutes are not directly related to preparing a patient for a paracentesis procedure.

2. A client with a history of chronic alcohol use is admitted with confusion and an unsteady gait. Which deficiency should the nurse suspect?

• A. Thiamine (Vitamin B1)
• B. Cyanocobalamin (Vitamin B12)
• C. Folic acid
• D. Vitamin D

Correct answer: A

Rationale: The correct answer is Thiamine (Vitamin B1). Chronic alcohol use can lead to thiamine deficiency, which can result in neurological symptoms such as confusion and an unsteady gait. Thiamine is essential for proper brain function and nerve conduction, and its deficiency is common in individuals with alcohol use disorder. Cyanocobalamin (Vitamin B12) deficiency can also present with neurological symptoms, but in this case, the patient's history of chronic alcohol use points more towards thiamine deficiency. Folic acid deficiency typically presents with symptoms like fatigue and megaloblastic anemia. Vitamin D deficiency is associated with bone health issues rather than neurological symptoms.

3. A client with a history of myocardial infarction (MI) is prescribed atorvastatin (Lipitor). Which outcome indicates that the medication is effective?

• A. Increased blood pressure.
• B. Lowered cholesterol levels.
• C. Decreased heart rate.
• D. Improved liver function.

Correct answer: B

Rationale: The correct answer is B: Lowered cholesterol levels. Atorvastatin is a medication commonly prescribed to lower cholesterol levels, which is crucial in reducing the risk of further cardiovascular events, including myocardial infarction (MI). Monitoring cholesterol levels is essential to assess the effectiveness of atorvastatin therapy and its role in preventing future cardiac complications. Choices A, C, and D are incorrect because increased blood pressure, decreased heart rate, and improved liver function are not direct indicators of atorvastatin's effectiveness in a client with a history of MI.

4. A client with heart failure is receiving intravenous furosemide (Lasix). Which assessment finding indicates that the medication is having the desired effect?

• A. Decreased peripheral edema.
• B. Elevated blood pressure.
• C. Increased heart rate.
• D. Decreased urine output.

Correct answer: A

Rationale: The correct answer is A: 'Decreased peripheral edema.' In a client with heart failure receiving furosemide, decreased peripheral edema indicates that the medication is effectively reducing fluid overload. Furosemide is a diuretic that helps the body eliminate excess fluid and salt through increased urine output, leading to a reduction in peripheral edema, which is a common symptom of heart failure. Monitoring and recognizing this improvement in edema are crucial in managing heart failure effectively.

5. The client has acute pancreatitis. Which nursing intervention is the highest priority?

• A. Administer pain medication as prescribed.
• B. Monitor the client's serum amylase and lipase levels.
• C. Encourage oral intake of clear liquids.
• D. Assess the client's bowel sounds every 4 hours.

Correct answer: A

Rationale: Administering pain medication as prescribed is the highest priority when caring for a client with acute pancreatitis. Acute pancreatitis is often associated with severe abdominal pain, and alleviating this pain is crucial for the client's comfort and well-being. Pain management can also help reduce stress on the pancreas and promote recovery. Monitoring serum amylase and lipase levels, encouraging oral intake of clear liquids, and assessing bowel sounds are important interventions but addressing the client's pain takes precedence to provide immediate relief and improve outcomes.

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