Nursing Elites

1. An older client is brought to the ED with a sudden onset of confusion that occurred after experiencing a fall at home. The client's daughter, who has power of attorney, has brought the client's prescriptions. Which information should the nurse provide first when reporting to the healthcare provider using SBAR communication?

• A. The client has been taking multiple medications
• B. The client is experiencing increasing confusion
• C. The client's vital signs are stable
• D. The client fell at home and has sustained bruises

Correct answer: B

Rationale: When utilizing the SBAR communication method, the nurse should prioritize reporting the client's increasing confusion to the healthcare provider first. Sudden onset of confusion in an older adult following a fall can indicate serious underlying conditions like a head injury, medication reaction, or infection. Addressing the confusion as the primary concern ensures prompt assessment and appropriate treatment. Choices A, C, and D are not as urgent as the client's increasing confusion and may be addressed after ensuring immediate attention to the potential critical issue.

2. A client is newly diagnosed with a duodenal ulcer. What information should the nurse provide during medication teaching?

• A. Take antacids regularly to manage symptoms.
• B. Avoid spicy foods and alcohol.
• C. Ensure proper administration of antibiotics.
• D. Stop all food intake until symptoms subside.

Correct answer: B

Rationale: The correct answer is B. Clients with duodenal ulcers should avoid spicy foods and alcohol as they can exacerbate symptoms and delay healing. Choice A is incorrect because while antacids may help with symptoms, they are not the primary focus of medication teaching for duodenal ulcers. Choice C is not directly related to medication teaching for duodenal ulcers unless antibiotics are specifically prescribed. Choice D is incorrect as stopping all food intake is not recommended and can lead to other complications.

3. A client is admitted with a large bowel obstruction. What finding should the nurse report immediately?

• A. Absence of bowel sounds in all four quadrants.
• B. Abdominal distention with a firm, rigid abdomen.
• C. Frequent, small, liquid stools.
• D. Nausea and vomiting that worsens after meals.

Correct answer: B

Rationale: Abdominal distention with a firm, rigid abdomen is a concerning sign that may indicate perforation, which requires immediate intervention. The rigidity suggests a complication of the large bowel obstruction. Absence of bowel sounds in all four quadrants, option A, is a common finding in a bowel obstruction but not as alarming as a rigid abdomen. Frequent, small, liquid stools, option C, are not typical findings in a large bowel obstruction; instead, constipation is more common. Nausea and vomiting that worsens after meals, option D, are also common symptoms of a bowel obstruction but do not indicate an immediate life-threatening complication like a perforation.

4. A client with tuberculosis (TB) is being discharged on isoniazid and rifampin. What instruction should the nurse prioritize?

• A. Complete the full course of antibiotics.
• B. Notify the healthcare provider if you experience tingling in your fingers.
• C. Use a disposable mask when in contact with others.
• D. Monitor liver function tests monthly.

Correct answer: C

Rationale: The correct answer is to instruct the client to use a disposable mask when in contact with others. TB is highly contagious, and wearing a mask can help prevent the spread of the disease to others. Choice A is important but not the priority as using a mask directly impacts public health. Choice B is related to a potential side effect of isoniazid, peripheral neuropathy, but immediate healthcare provider notification is not required. Choice D is relevant due to the potential hepatotoxicity of isoniazid and rifampin, but it is not the priority instruction in this scenario.

5. A client receiving lactulose for hepatic encephalopathy needs evaluation. Which assessment should the nurse prioritize?

• A. Percussion of the abdomen.
• B. Blood glucose level.
• C. Serum electrolytes.
• D. Level of consciousness.

Correct answer: D

Rationale: The correct answer is D: Level of consciousness. When managing hepatic encephalopathy with lactulose, monitoring the client's level of consciousness is crucial as it is a key indicator of the therapeutic response to lactulose in reducing ammonia levels. Changes in consciousness can reflect the effectiveness of treatment and the progression of hepatic encephalopathy. Option A, percussion of the abdomen, is not directly related to evaluating the response to lactulose. Option B, blood glucose level, is important but not the priority in this context. Option C, serum electrolytes, while significant in liver disease, do not directly assess the impact of lactulose therapy on hepatic encephalopathy.

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