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. An adolescent's mother calls the clinic because the teen is having recurrent vomiting and has become combative in the last 2 days. The mother states that the teen takes vitamins, calcium, magnesium, and aspirin. Which nursing intervention has the highest priority?

• A. Advise the mother to withhold all medications by mouth.
• B. Instruct the mother to take the teen to the emergency room.
• C. Recommend that the teen withhold food and fluids for 2 hours.
• D. Suggest that the adolescent breathe slowly and deeply.

Correct answer: B

Rationale: The correct answer is to instruct the mother to take the teen to the emergency room. The symptoms described, including recurrent vomiting and becoming combative after taking vitamins, calcium, magnesium, and aspirin, indicate a potential overdose or a serious condition. Therefore, immediate medical evaluation in the emergency room is crucial. Advising to withhold all medications by mouth (Choice A) may delay necessary treatment. Recommending to withhold food and fluids (Choice C) is not appropriate in this urgent situation. Suggesting deep breathing (Choice D) does not address the seriousness of the symptoms and the need for immediate medical attention.

3. A male client with cancer who has lost 10 pounds during the last months tells the nurse that beef, chicken, and eggs, which used to be his favorite foods, now taste 'bitter'. He complains that he simply has no appetite. What action should the nurse implement?

• A. Suggest the use of alternative sources of protein such as dairy products and nuts.
• B. Encourage the client to eat smaller, more frequent meals.
• C. Offer nutritional supplements between meals.
• D. Discuss the possibility of appetite stimulants with the healthcare provider.

Correct answer: A

Rationale: Offering alternative protein sources like dairy products and nuts can help maintain nutrition when the client finds certain foods unpalatable, as in this case where beef, chicken, and eggs taste 'bitter'. Encouraging smaller, more frequent meals may not address the issue of unpalatable foods. Offering nutritional supplements between meals may not specifically address the problem of protein intake. Discussing appetite stimulants should be considered after exploring less invasive options first.

4. Following discharge teaching, a male client with a duodenal ulcer tells the nurse he will drink plenty of dairy products to help coat and protect his ulcer. What is the best follow-up action by the nurse?

• A. Remind the client that it is also important to switch to decaffeinated coffee and tea.
• B. Suggest that the client also plans to eat frequent small meals to reduce discomfort.
• C. Review with the client the need to avoid foods that are rich in milk and cream.
• D. Reinforce this teaching by asking the client to list a dairy food that he might select.

Correct answer: C

Rationale: The correct answer is C because diets rich in milk and cream stimulate gastric acid secretion, which can exacerbate a duodenal ulcer. Therefore, it is essential to avoid foods that are rich in milk and cream. Choice A is incorrect because switching to decaffeinated coffee and tea does not address the issue of avoiding milk and cream products. Choice B is incorrect because while eating frequent small meals can help with discomfort, it does not address the specific issue of avoiding milk and cream. Choice D is incorrect as it does not address the need to avoid milk and cream products.

5. Which instruction is most important for a client who receives a new plan of care to treat osteoporosis?

• A. Start a weight-bearing exercise plan.
• B. Increase consumption of foods rich in calcium.
• C. Arrange a bone density test every year.
• D. Stay upright after taking the medication.

Correct answer: D

Rationale: The correct answer is D: 'Stay upright after taking the medication.' This instruction is crucial for clients receiving medications like bisphosphonates to prevent esophageal irritation or erosion. While weight-bearing exercises (choice A) are important for bone health, staying upright after medication intake takes precedence. Increasing calcium-rich foods (choice B) is beneficial but not the most important immediate instruction. Scheduling bone density tests (choice C) is necessary for monitoring osteoporosis but is not as critical as staying upright after medication.

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