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 male client is having abdominal pain after a left femoral angioplasty and stent, and is asking for additional pain medication for right lower quadrant pain (9/10). Two hours ago, he received hydrocodone/acetaminophen 7.5/325 mg. His vital signs are elevated from previous readings: temperature 97.8°F, heart rate 102 beats/minute, respiration 20 breaths/minute. His abdomen is swollen, the groin access site is tender, peripheral pulses are present, but the left is greater than the right. What data is needed to make this report complete?

• A. Client's lungs are clear bilaterally, and oxygen saturation is 97%.
• B. Surgeon needs to see the client immediately to evaluate the situation.
• C. Left peripheral pulses were present only by Doppler pre-procedure.
• D. Client's history includes multiple back surgeries and chronic pain.

Correct answer: B

Rationale: The correct answer is B. In this scenario, the client is experiencing abdominal pain after a left femoral angioplasty and stent, with signs of potential complications such as a swollen abdomen, tenderness at the groin access site, and unequal peripheral pulses. The client's vital signs are also elevated, indicating a worsening condition. Given these findings, the immediate evaluation by the surgeon is crucial to assess for serious complications like internal bleeding or ischemia. Choice A is incorrect as the focus should be on the urgent need for surgical evaluation rather than lung sounds and oxygen saturation. Choice C is irrelevant to the immediate management of the client's current situation. Choice D, while providing background information, is not essential for the urgent intervention required in this case.

3. A client with a tracheostomy has thick, tenacious secretions. Which intervention should the nurse include in the plan of care?

• A. Encourage the client to drink plenty of fluids.
• B. Perform deep suctioning every 2 to 4 hours.
• C. Increase humidity in the client's room.
• D. Administer a mucolytic agent.

Correct answer: C

Rationale: Increasing humidity in the client's room can help liquefy thick secretions and facilitate easier airway clearance in a client with a tracheostomy. Encouraging the client to drink plenty of fluids can be beneficial for overall hydration but may not directly address thick secretions. Deep suctioning every 2 to 4 hours can be harmful and cause trauma to the airway lining. Administering a mucolytic agent should be done under the healthcare provider's order and may not be the initial intervention for thick secretions.

4. An 11-year-old client is admitted to the mental health unit after trying to run away from home and threatening self-harm. The nurse establishes a goal to promote effective coping and plans to ask the client to verbalize three ways to deal with stress. Which activity is best to establish rapport and accomplish this therapeutic goal?

• A. Play a board game with the client and begin talking about stressors
• B. Conduct a formal therapy session
• C. Ask the client to write down their feelings
• D. Have a group discussion about stress management

Correct answer: A

Rationale: Playing a board game with the client and initiating a conversation about stressors is the best choice to establish rapport and achieve the therapeutic goal of helping the client verbalize ways to cope with stress. Board games provide a relaxed and non-threatening environment, allowing the client to feel more comfortable and open up about their stressors. Choice B, conducting a formal therapy session, might be too structured and intimidating for the client, hindering open communication. Choice C, asking the client to write down their feelings, lacks the interactive and engaging aspect that a board game provides. Choice D, having a group discussion about stress management, may not be as effective initially as one-on-one interaction to build trust and rapport with the client.

5. A client with a history of chronic heart failure is admitted with shortness of breath and crackles in the lungs. Which intervention should the nurse implement first?

• A. Administer oxygen therapy as prescribed.
• B. Administer a loop diuretic as prescribed.
• C. Administer intravenous morphine as prescribed.
• D. Obtain an arterial blood gas (ABG) sample.

Correct answer: A

Rationale: Administering oxygen therapy is the priority intervention for a client with chronic heart failure presenting with shortness of breath and crackles in the lungs. Oxygen therapy helps improve oxygenation, which is crucial in managing respiratory distress. Loop diuretics (Choice B) may be indicated to manage fluid overload in heart failure but are not the immediate priority in this case. Administering morphine (Choice C) is not the first-line intervention for shortness of breath in heart failure and should be considered after addressing oxygenation and underlying causes. Obtaining an arterial blood gas sample (Choice D) can provide valuable information but is not the initial action needed to address the client's acute respiratory distress.

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