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. A client with a history of angina pectoris is prescribed sublingual nitroglycerin. Which client statement indicates that further teaching is needed?

• A. ‘I should take the nitroglycerin with a full glass of water.’
• B. ‘I should take the nitroglycerin as soon as I feel chest pain.’
• C. ‘I can take up to three doses of nitroglycerin if needed.’
• D. ‘I should call 911 if my chest pain does not improve after the first dose.’

Correct answer: A

Rationale: The correct answer is A. Sublingual nitroglycerin should not be taken with water, as it needs to dissolve under the tongue to be effective. Option B is correct as the client should take nitroglycerin as soon as they feel chest pain. Option C is correct as up to three doses can be taken if needed. Option D is correct as the client should seek emergency help if chest pain does not improve after the first dose.

3. A female client has been taking a high dose of prednisone, a corticosteroid, for several months. After stopping the medication abruptly, the client reports feeling 'very tired'. Which nursing intervention is most important for the nurse to implement?

• A. Measure vital signs
• B. Auscultate breath sounds
• C. Palpate the abdomen
• D. Observe the skin for bruising

Correct answer: A

Rationale: The correct answer is to measure vital signs. Abrupt withdrawal of exogenous corticosteroids can precipitate adrenal insufficiency, potentially leading to shock. Monitoring vital signs is crucial in identifying any signs of adrenal insufficiency, such as hypotension or tachycardia. Auscultating breath sounds (choice B) may be important in other situations, such as respiratory conditions, but it is not the priority in this case. Palpating the abdomen (choice C) and observing the skin for bruising (choice D) are not directly related to the potential complications of corticosteroid withdrawal and adrenal insufficiency.

4. The healthcare provider is assessing a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which clinical finding is most concerning?

• A. Increased fatigue
• B. Elevated blood pressure
• C. Elevated hemoglobin
• D. Low urine output

Correct answer: B

Rationale: In a client with chronic kidney disease (CKD) receiving erythropoietin therapy, elevated blood pressure is the most concerning finding. Elevated blood pressure can indicate worsening hypertension, which requires immediate intervention to prevent further damage to the kidneys and other organs. Increased fatigue (choice A) is a common symptom in CKD but may not be as acutely concerning as elevated blood pressure. Elevated hemoglobin (choice C) can be an expected outcome of erythropoietin therapy and is not necessarily concerning. Low urine output (choice D) is important to monitor in CKD but may not be as immediately concerning as elevated blood pressure in this context.

5. An 80-year-old male client with multiple chronic health problems becomes disoriented, agitated, and combative 24 hours after being admitted to the hospital. What nursing intervention is most important to include in this client's plan of care?

• A. Request a psychiatric consultation for the client.
• B. Reorient the client frequently to time, place, and person.
• C. Administer prescribed antipsychotic medications to reduce agitation.
• D. Obtain an order for a sitter to stay with the client.

Correct answer: B

Rationale: Reorienting the client frequently is the most important nursing intervention in this scenario. It helps reduce confusion and agitation, which are common symptoms of acute delirium in hospitalized elderly clients. Requesting a psychiatric consult (choice A) may be necessary if the reorientation does not improve the client's condition or if there are underlying psychiatric concerns, but reorientation should be attempted first. Administering antipsychotic medications (choice C) should not be the initial intervention as they can have adverse effects in elderly individuals. Obtaining a sitter (choice D) may provide support but does not directly address the client's disorientation and agitation.

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