Nursing Elites

1. An adult client undergoes various diagnostic tests to determine the pumping ability of the heart. The nurse notes that the results of these tests indicate that the client's cardiac output is 5 L/min. The nurse makes which conclusion?

• A. The client has a low cardiac output.
• B. The client has a high cardiac output.
• C. The client has a normal cardiac output.
• D. The client will need a blood transfusion.

Correct answer: C

Rationale: A cardiac output of 5 L/min falls within the normal range for a resting adult, which typically ranges between 4 and 6 L/min. Cardiac output is calculated as the stroke volume (volume of blood in each systole) multiplied by the heart rate. Therefore, a cardiac output of 5 L/min is considered normal. Choices A and B are incorrect as they misinterpret the result as either low or high, which is not the case based on the provided information. Choice D is unrelated to the client's cardiac output and thus incorrect.

2. While reviewing a client's health care record, a nurse notes documentation of the presence of borborygmus on abdominal assessment. Which finding does the nurse expect to note when auscultating the client's bowel sounds?

• A. Hypoactive bowel sounds
• B. Low-pitched bowel sounds
• C. Hyperactive bowel sounds
• D. An absence of bowel sounds

Correct answer: C

Rationale: Borborygmus, a type of hyperactive bowel sound, is fairly common. It indicates hyperperistalsis, and the client may describe it as a growling stomach. Hyperactive bowel sounds are loud, high-pitched, and rushing sounds. Hypoactive bowel sounds are low-pitched and may occur post-surgery or with peritoneal inflammation. Low-pitched bowel sounds are not typically associated with borborygmus. An absence of bowel sounds indicates a potentially serious issue like an ileus, where bowel motility is decreased or absent.

3. The nurse receives an order to administer phenytoin through the client's J-tube. The order instructs that tube feedings are stopped at least an hour prior to administering the medication and an hour after the medication is administered. Which of the following considerations may be a reason to discuss this order with the physician?

• A. The client has a history of Type II diabetes.
• B. The client is on a continuous tube-feeding regimen.
• C. The client is on fluid restriction.
• D. The pharmacy has provided phenytoin in tablet form.

Correct answer: B

Rationale: For a client on a continuous tube-feeding regimen, stopping tube feedings for two hours to administer this medication may compromise the client's nutritional status. This interruption can lead to inadequate nutrient intake, affecting the client's overall nutritional well-being. The other choices are less relevant in this situation. Type II diabetes does not directly impact the administration of phenytoin through a J-tube. Fluid restriction would not prevent the temporary interruption of tube feedings for medication administration. The form of phenytoin provided by the pharmacy does not impact the need to discuss the order with the physician regarding the client's continuous tube-feeding regimen.

4. A 17-year-old female was raped by a young man in her neighborhood. She is in the Emergency Department for evaluation and tests. After the procedure is completed, a rape crisis counselor (nurse specialist) talks to the client in a conference room regarding the rape. Implementing counseling by the nurse specialist for the raped victim represents:

• A. assessment.
• B. crisis intervention.
• C. empathetic concern.
• D. unwarranted intrusion

Correct answer: B

Rationale: Crisis intervention is the correct choice. Counseling by a nurse specialist after a traumatic event like rape falls under the Crisis Intervention Model. This approach aims to provide immediate support to individuals facing a crisis to enhance coping mechanisms. In this scenario, the nurse specialist is offering specialized care tailored to rape victims, helping the client navigate through the emotional aftermath of the traumatic experience. Choices A, C, and D are incorrect: A is not the correct answer as the nurse specialist is providing emotional support rather than conducting an assessment; C, while important, does not fully capture the specialized intervention being provided; and D is inaccurate as the nurse specialist's intervention is warranted and essential for the victim's well-being.

5. The nurse notes that a client in later adulthood has tremors of the hands. Based on this finding, what action should the nurse take?

• A. Ask the healthcare provider about referring the client to a neurological specialist.
• B. Obtain a prescription for a muscle relaxant.
• C. Notify the healthcare provider immediately.
• D. Document the findings.

Correct answer: D

Rationale: When a nurse observes senile tremors, such as intentional tremor of the hands in a client in later adulthood, it is important to document the findings. Senile tremors are benign and a normal age-related occurrence. Referring the client to a neurological specialist (Choice A) is unnecessary as senile tremors do not require specialized neurological intervention. Prescribing a muscle relaxant (Choice B) is not indicated since senile tremors are benign and not typically treated with muscle relaxants. Notifying the healthcare provider immediately (Choice C) is unnecessary as senile tremors do not require urgent intervention. Therefore, the most appropriate action is to document the findings (Choice D) for the client's medical record and to establish a baseline for future assessments.

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