Nursing Elites

1. After receiving lactulose, a client with hepatic encephalopathy has several loose stools. What action should the nurse implement?

• A. Send stool specimen to the lab
• B. Measure abdominal girth
• C. Encourage increased fiber in the diet
• D. Monitor mental status

Correct answer: D

Rationale: The correct action for the nurse to implement after a client with hepatic encephalopathy has loose stools following lactulose administration is to monitor the client's mental status. Lactulose is given to lower serum ammonia levels in hepatic encephalopathy, and loose stools can be an expected side effect of its use. Monitoring mental status is crucial because changes in mental status, such as confusion or altered level of consciousness, are key indicators of hepatic encephalopathy worsening. Sending a stool specimen to the lab would not be the priority in this situation as loose stools are a known effect of lactulose. Measuring abdominal girth is more relevant for conditions like ascites, not loose stools. Encouraging increased fiber in the diet may be beneficial for constipation but is not the immediate action needed when loose stools occur after lactulose administration.

2. The charge nurse of the critical care unit informed at the beginning of the shift that a less than optimal number of registered nurses would be working that shift. In planning assignments, which client should receive the most care hours by a registered nurse?

• A. A 34-year-old admitted today after an emergency appendectomy who has a peripheral intravenous catheter and a Foley catheter.
• B. A 48-year-old marathon runner with a central venous catheter experiencing nausea and vomiting due to electrolyte disturbance following a race.
• C. A 63-year-old chain smoker with chronic bronchitis receiving oxygen via nasal cannula and a saline-locked peripheral intravenous catheter.
• D. An 82-year-old client with Alzheimer's disease and a newly fractured femur with a Foley catheter and soft wrist restraints applied.

Correct answer: D

Rationale: The 82-year-old client with Alzheimer's disease and a newly fractured femur should receive the most care hours by a registered nurse because they are at the highest risk for injury and complications. The client's age, diagnosis of Alzheimer's disease, and the presence of a newly fractured femur along with the Foley catheter and wrist restraints indicate a need for close monitoring and care. Choice A is less critical as the client is stable post-appendectomy. Choice B, though experiencing symptoms, is not at the same level of risk as the client in Choice D. Choice C, while requiring oxygen support, does not have the same level of acuity and complexity as the client in Choice D.

3. A female client with breast cancer who completed her first chemotherapy treatment today at an outpatient center is preparing for discharge. Which behavior indicates that the client understands her care needs?

• A. Rented movies and borrowed books to use while passing time at home
• B. Made an appointment with the oncologist for follow-up treatment
• C. Expressed concern about hair loss and fatigue
• D. Asked for dietary recommendations to manage nausea

Correct answer: A

Rationale: Choice A is the correct answer. Renting movies and borrowing books to use at home indicate that the client understands the need for rest and self-care after chemotherapy. This behavior demonstrates the client's intention to engage in activities that promote relaxation and recovery. Choices B, C, and D are incorrect because making an appointment for follow-up treatment, expressing concern about side effects like hair loss and fatigue, and asking for dietary recommendations are important but do not directly reflect the client's understanding of her immediate care needs post-chemotherapy.

4. A newly graduated female staff nurse requests reassignment to another client because a male client is asking her for a date and making suggestive comments. Which response is best for the nurse manager to provide?

• A. I have to call the supervisor to get someone else to transfer to this unit to care for him.
• B. I know you are a good nurse and can handle this client in a professional manner.
• C. I'll talk to the client about his behavior and insist that he stop it immediately.
• D. I'll change your assignment, but let's talk about how a nurse should respond to this kind of client.

Correct answer: D

Rationale: The best response for the nurse manager to provide in this situation is option D, which involves changing the assignment to address the nurse's immediate concern. It also offers an opportunity to have a conversation with the nurse about how to professionally handle such situations in the future. Option A is not the best response as it does not address the underlying issue and simply shifts the problem to another staff member. Option B, while supportive, does not actively address the client's inappropriate behavior. Option C is not ideal as the nurse manager should handle discussions about inappropriate behavior with clients themselves rather than delegating it to the staff nurse.

5. When administering ceftriaxone sodium (Rocephin) intravenously to a client, which assessment finding requires the most immediate intervention by the nurse?

• A. Stridor
• B. Nausea
• C. Headache
• D. Pruritus

Correct answer: A

Rationale: The correct answer is A: Stridor. Stridor is a high-pitched, noisy breathing sound that indicates a potential airway obstruction, which can be caused by an allergic reaction. This finding requires immediate intervention by the nurse to ensure the client's airway is patent and to prevent respiratory distress. Nausea, headache, and pruritus are potential side effects of ceftriaxone sodium but do not pose immediate life-threatening risks compared to airway obstruction indicated by stridor.

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