Nursing Elites

1. The nurse is caring for a client with acute pancreatitis. Which intervention should be included in the plan of care?

• A. Provide a high-protein diet
• B. Encourage oral fluids
• C. Administer intravenous fluids as prescribed
• D. Monitor for signs of hyperglycemia

Correct answer: C

Rationale: The correct intervention to include in the plan of care for a client with acute pancreatitis is to administer intravenous fluids as prescribed. Intravenous fluids are crucial to maintain hydration and electrolyte balance in clients with acute pancreatitis. Providing a high-protein diet (Choice A) is not recommended initially for clients with acute pancreatitis, as they may need to be kept NPO (nothing by mouth) to rest the pancreas. Encouraging oral fluids (Choice B) may not be appropriate if the client is experiencing severe symptoms and requires intravenous fluids. Monitoring for signs of hyperglycemia (Choice D) is important but not the immediate intervention needed to address the fluid and electrolyte imbalances associated with acute pancreatitis.

2. A client with a history of hypertension is prescribed hydrochlorothiazide (HCTZ). Which adverse effect should the nurse monitor for?

• A. Hyperkalemia
• B. Hyponatremia
• C. Bradycardia
• D. Hyperglycemia

Correct answer: B

Rationale: The correct answer is 'B. Hyponatremia.' Hydrochlorothiazide can lead to electrolyte imbalances, such as hyponatremia, due to its diuretic effect. This potential adverse effect should be closely monitored in patients taking HCTZ. Choice A, hyperkalemia, is less likely to occur with HCTZ as it tends to cause hypokalemia. Choice C, bradycardia, is not a common adverse effect of HCTZ. Choice D, hyperglycemia, is also less commonly associated with HCTZ use compared to hyponatremia.

3. A new father asks the nurse the reason for placing an ophthalmic ointment in his newborn's eyes. What information should the nurse provide?

• A. Possible exposure to an environmental staphylococcus infection can infect the newborn's eyes and cause visual deficits
• B. The newborn is at risk for blindness from a corneal syphilitic infection acquired from a mother's infected vagina
• C. Treatment prevents tear duct obstruction with harmful exudate from a vaginal birth that can lead to dry eyes in the newborn
• D. State law mandates all newborns receive prophylactic treatment to prevent gonorrheal or chlamydial ophthalmic infection

Correct answer: D

Rationale: The correct answer is D because informing about state law emphasizes the legal requirement and public health rationale behind prophylactic eye treatment to prevent serious infections like gonorrheal or chlamydial ophthalmic infection. Choices A, B, and C are incorrect. Choice A focuses on staphylococcus infection, which is not the primary concern addressed by the prophylactic ointment. Choice B mentions a specific infection acquired from the mother's infected vagina, which is not the main reason for the ophthalmic ointment. Choice C discusses tear duct obstruction and dry eyes, which are not the primary concerns addressed by the prophylactic ointment.

4. The nurse is caring for a client with cirrhosis of the liver. Which clinical finding is most concerning?

• A. Jaundice.
• B. Ascites.
• C. Spider angiomas.
• D. Asterixis.

Correct answer: D

Rationale: The correct answer is D, Asterixis. Asterixis, also known as liver flap, is a sign of hepatic encephalopathy, a severe complication of liver disease that necessitates immediate attention. While jaundice (choice A), ascites (choice B), and spider angiomas (choice C) are common clinical findings in cirrhosis, asterixis is the most concerning due to its association with hepatic encephalopathy, which can lead to altered mental status and even coma. Jaundice, ascites, and spider angiomas are also important signs in cirrhosis, but asterixis indicates a more critical condition requiring urgent intervention.

5. A client with a diagnosis of hypothyroidism is being treated with levothyroxine (Synthroid). What is the most important information for the nurse to provide?

• A. Take the medication at bedtime.
• B. Take the medication with food.
• C. Report any symptoms of hyperthyroidism.
• D. Discontinue the medication if you feel well.

Correct answer: C

Rationale: The most important information for the nurse to provide to a client with hypothyroidism being treated with levothyroxine is to report any symptoms of hyperthyroidism. Symptoms of hyperthyroidism, such as palpitations or tremors, may indicate overtreatment or excessive dosing of levothyroxine. Prompt reporting of these symptoms is crucial to prevent serious complications. Choices A and B are not the most critical information related to levothyroxine administration. Instructing the client to take the medication at bedtime or with food can be important for adherence but is not as crucial as monitoring for signs of hyperthyroidism. Choice D is incorrect as discontinuing the medication if feeling well can lead to a relapse of hypothyroidism symptoms.

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