Nursing Elites

1. The nurse assesses a client with advanced cirrhosis of the liver for signs of hepatic encephalopathy. Which finding would the nurse consider an indication of progressive hepatic encephalopathy?

• A. An increase in abdominal girth.
• B. Hypertension and a bounding pulse.
• C. Decreased bowel sounds.
• D. Difficulty in handwriting.

Correct answer: D

Rationale: Difficulty in handwriting is a common early sign of hepatic encephalopathy. Changes in handwriting can indicate progression or reversal of hepatic encephalopathy leading to coma. Choice (A) is a sign of ascites, not hepatic encephalopathy. Hypertension and a bounding pulse (Choice B) are not typically associated with hepatic encephalopathy. Decreased bowel sounds (Choice C) do not directly indicate an increase in serum ammonia level, which is the primary cause of hepatic encephalopathy.

2. A nurse has a prescription to insert a nasogastric tube into the stomach of an assigned client. Which action should the nurse take to insert the tube safely and easily?

• A. Placing the tube in warm water
• B. Hyperextending the head while inserting the tube
• C. Removing the tube if any resistance to insertion is met
• D. Asking the client to swallow as the tube is being advanced

Correct answer: D

Rationale: The correct action for the nurse to take to insert a nasogastric tube safely and easily is asking the client to swallow as the tube is being advanced. This action helps facilitate the passage of the tube through the esophagus into the stomach. Placing the tube in warm water (Choice A) is not a recommended practice for nasogastric tube insertion. Hyperextending the head (Choice B) can cause discomfort and is not necessary for safe insertion. Removing the tube if resistance is met (Choice C) is incorrect as it may cause harm or discomfort to the client. Asking the client to swallow helps the tube pass more smoothly and comfortably.

3. The client has been managing angina episodes with nitroglycerin. Which of the following indicates the drug is effective?

• A. Decreased chest pain.
• B. Increased blood pressure.
• C. Decreased blood pressure.
• D. Decreased heart rate.

Correct answer: A

Rationale: The correct answer is A: Decreased chest pain. Nitroglycerin is a vasodilator that works by decreasing myocardial oxygen consumption, which helps to reduce chest pain caused by angina. Therefore, a reduction in chest pain is a positive indicator of the drug's effectiveness. Choices B, C, and D are incorrect because nitroglycerin does not typically increase blood pressure or heart rate; instead, it often causes a decrease in blood pressure due to vasodilation and may cause a reflex tachycardia (increased heart rate) as a compensatory response to lowered blood pressure.

4. In a client with heart failure presenting bilateral +4 edema of the right ankle extending up to midcalf while sitting with legs dependent, what is the priority goal?

• A. Decrease venous congestion.
• B. Maintain normal respirations.
• C. Maintain body temperature.
• D. Prevent injury to lower extremities.

Correct answer: A

Rationale: The priority goal in this scenario is to decrease venous congestion. By elevating the legs above the heart level, venous return is improved, reducing congestion in the lower extremities. This intervention helps decrease swelling and prevents complications such as impaired tissue perfusion. Maintaining normal respirations and body temperature are important aspects of care but are secondary to addressing the immediate issue of venous congestion. Preventing injury to lower extremities is also essential but takes precedence after managing the venous congestion to prevent further complications.

5. A client with nephrotic syndrome is being assessed by a nurse. For which clinical manifestations should the nurse assess? (Select all that apply.)

• A. Proteinuria
• B. Hypoalbuminemia
• C. Lipiduria
• D. All of the above

Correct answer: D

Rationale: Nephrotic syndrome is characterized by glomerular damage, leading to proteinuria (excessive protein in the urine), hypoalbuminemia (low levels of albumin in the blood), and lipiduria (lipids in the urine). These manifestations are key indicators of nephrotic syndrome. Edema, often severe, is also common due to decreased plasma oncotic pressure from hypoalbuminemia. The correct answer is 'All of the above' because all three manifestations are associated with nephrotic syndrome. Dehydration is not a typical finding in nephrotic syndrome as it is more commonly associated with fluid retention and edema. Dysuria is a symptom of cystitis, not nephrotic syndrome. CVA tenderness is more indicative of inflammatory changes in the kidney rather than nephrotic syndrome.

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