Nursing Elites

1. The healthcare provider is completing a head-to-toe assessment for a client admitted for observation after falling out of a tree. Which finding warrants immediate intervention by the healthcare provider?

• A. Sluggish pupillary response to light
• B. Clear fluid leaking from the nose
• C. Complaint of severe headache
• D. Periorbital ecchymosis of the right eye

Correct answer: B

Rationale: Clear fluid leaking from the nose is concerning for cerebrospinal fluid leakage, which is a medical emergency requiring immediate intervention. Sluggish pupillary response to light may indicate neurological issues but is not as urgent as CSF leakage. Complaint of severe headache is important but not as critical as the possibility of CSF leakage. Periorbital ecchymosis of the right eye could be indicative of trauma but does not pose an immediate threat to the patient's life.

2. A client has had several episodes of clear, watery diarrhea that started yesterday. What action should the nurse implement?

• A. Administer a prescribed PRN antiemetic
• B. Assess the client for the presence of hemorrhoids
• C. Check the client’s hemoglobin level
• D. Review the client’s current list of medications

Correct answer: D

Rationale: The correct action for the nurse to implement in a client experiencing clear, watery diarrhea is to review the client's current list of medications. Certain medications can cause diarrhea as a side effect, so identifying any potential culprits is essential. Administering an antiemetic (Choice A) is not appropriate for diarrhea, as antiemetics are used to control nausea and vomiting, not diarrhea. Assessing for hemorrhoids (Choice B) is not the priority when the client is experiencing watery diarrhea; addressing the root cause is crucial. Checking the client’s hemoglobin level (Choice C) is not the immediate action needed for this situation as it does not directly address the cause of diarrhea.

3. A female client reports she has not had a bowel movement for 3 days, but now is defecating frequent small amounts of liquid stool. Which action should the nurse implement?

• A. Digitally check the client for a fecal impaction
• B. Increase fluid intake to promote bowel regularity
• C. Provide a high-fiber diet to facilitate bowel movements
• D. Administer a stool softener

Correct answer: A

Rationale: The correct answer is A: Digitally check the client for a fecal impaction. Small, frequent liquid stools following constipation may indicate a fecal impaction. This intervention is crucial to assess and address a potential impaction promptly. Choices B, increasing fluid intake, and C, providing a high-fiber diet, may help with bowel regularity in general cases, but they don't directly address the urgent concern of a possible impaction. Choice D, administering a stool softener, is not appropriate as the first action when a fecal impaction is suspected; it could worsen the condition by causing further liquid stool output without addressing the impaction.

4. Following rectal surgery, a female client is very anxious about the pain she may experience during defecation. The nurse should collaborate with the healthcare provider to administer which type of medication?

• A. Bulk-forming agent
• B. Antianxiety agent
• C. Stool softener
• D. Stimulant cathartic

Correct answer: C

Rationale: After rectal surgery, a stool softener is the most appropriate medication to help prevent pain and straining during defecation. Stool softeners work by increasing the water content of the stool, making it easier to pass without discomfort. Bulk-forming agents (Choice A) help add mass to the stool but may not address the immediate post-operative discomfort. Antianxiety agents (Choice B) would address the anxiety but not the physical discomfort. Stimulant cathartics (Choice D) are not recommended after rectal surgery as they can cause cramping and increased bowel movements, potentially exacerbating pain.

5. The nurse is assessing a client with left-sided heart failure who reports nocturia and dyspnea. The nurse identifies pulsus alternans and crackles in all lung fields. Which action is best to include in the client’s plan of care?

• A. Begin client education about positive inotropic medications.
• B. Place the client in Trendelenburg position.
• C. Prepare the client for an emergency cardiac catheterization.
• D. Monitor serum Troponin, CK, and CK-MB levels.

Correct answer: A

Rationale: In the scenario described, the client is exhibiting signs of left-sided heart failure, such as dyspnea, nocturia, pulsus alternans, and crackles in all lung fields. Positive inotropic medications are commonly used in the treatment of heart failure to improve cardiac contractility and output. Therefore, beginning client education about positive inotropic medications is the best action to include in the client's plan of care. Choice B is incorrect because placing the client in Trendelenburg position is not indicated in the management of left-sided heart failure. Choice C is incorrect as emergency cardiac catheterization is not typically the initial intervention for left-sided heart failure. Choice D is incorrect as monitoring serum Troponin, CK, and CK-MB levels is more pertinent to assessing for myocardial infarction rather than managing heart failure.

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