Nursing Elites

1. The healthcare provider prescribes a sepsis protocol for a client with multi-organ failure caused by a ruptured appendix. Which intervention is most important for the nurse to include in the care plan?

• A. Ensure early ambulation
• B. Administer antibiotics as prescribed
• C. Maintain strict intake and output
• D. Monitor blood glucose levels

Correct answer: C

Rationale: In sepsis with multi-organ failure, monitoring intake and output is critical to assess renal function and fluid balance, as organ failure can cause fluid shifts and decreased kidney function. Antibiotics are essential to treat the infection, but monitoring intake and output provides real-time insight into the client's status, helping to detect early signs of worsening organ function. Early ambulation and blood glucose monitoring are important aspects of care but are not as crucial as maintaining strict intake and output in this situation.

2. The nurse is caring for a client with pancreatitis who is receiving total parenteral nutrition (TPN). Which assessment finding requires immediate intervention by the nurse?

• A. Blood glucose level of 200 mg/dL
• B. The client reports feeling weak and shaky
• C. The TPN bag is 5% dextrose
• D. The client reports feeling thirsty

Correct answer: B

Rationale: The correct answer is B. Weakness and shakiness can indicate hypoglycemia, a potential complication of TPN. Immediate intervention is necessary to assess blood glucose levels and provide treatment as needed. Choice A is incorrect because a blood glucose level of 200 mg/dL is within an acceptable range and does not require immediate intervention. Choice C is incorrect as a 5% dextrose TPN bag is a standard concentration. Choice D is also incorrect as feeling thirsty is not a critical assessment finding requiring immediate intervention in this context.

3. 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.

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

• A. Encourage the client to drink milk
• B. Review with the client the need to avoid foods that are rich in milk and cream
• C. Instruct the client to take antacids instead
• D. Advise the client to monitor their symptoms

Correct answer: B

Rationale: The client should be advised to avoid foods rich in milk and cream. Although they provide temporary relief, dairy products, especially milk, stimulate gastric acid secretion, which can exacerbate the symptoms of a duodenal ulcer. Encouraging the client to drink milk (Choice A) would be counterproductive and could worsen the condition. Instructing the client to take antacids (Choice C) may provide symptomatic relief but does not address the root cause of the issue. Advising the client to monitor their symptoms (Choice D) is vague and does not provide specific guidance on managing the duodenal ulcer. Therefore, the best action is to review with the client the need to avoid foods rich in milk and cream to ensure proper ulcer management.

5. The nurse is caring for a client with deep vein thrombosis (DVT) who is receiving heparin therapy. Which assessment finding requires immediate intervention by the nurse?

• A. Localized warmth
• B. Calf pain
• C. Swelling in the affected leg
• D. Hematuria

Correct answer: D

Rationale: Hematuria is a sign of bleeding, which is a potential complication of heparin therapy. Immediate intervention is required to manage the bleeding and adjust the heparin dosage if necessary. Localized warmth, calf pain, and swelling in the affected leg are common findings in clients with DVT and receiving heparin therapy. While these symptoms should be monitored, hematuria indicates a more serious issue requiring immediate attention.

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