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. The client is assessing a client who was recently diagnosed with heart failure and is on a low-sodium diet. Which statement by the client indicates a need for further teaching?

• A. “I will use lemon juice and herbs for flavoring.”
• B. “I will not eat canned soups or frozen dinners.”
• C. “I can have salt substitutes to enhance the taste of my food.”
• D. “I will check the food labels for sodium content before buying.”

Correct answer: C

Rationale: The correct answer is C. Some salt substitutes can be high in potassium, which may not be suitable for clients with heart failure. Option A is correct as using lemon juice and herbs for flavoring is a good low-sodium alternative. Option B is also correct as canned soups and frozen dinners are typically high in sodium content. Option D is correct as checking food labels for sodium content is an essential part of managing a low-sodium diet. Therefore, the client's statement about using salt substitutes needs correction as it can introduce high levels of potassium, which may not be recommended for individuals with heart failure.

3. Which client should the nurse assess frequently because of the risk for overflow incontinence?

• A. A client who is bedfast, with increased serum BUN and creatinine levels
• B. A client with hematuria and decreasing hemoglobin and hematocrit levels
• C. A client who has a history of frequent urinary tract infections
• D. A client who is confused and frequently forgets to go to the bathroom

Correct answer: A

Rationale: The correct answer is A. Bedfast clients with increased serum BUN and creatinine levels are at high risk for overflow incontinence. This occurs due to decreased bladder function and reduced ability to sense bladder fullness, leading to the bladder overfilling and leaking urine. Choice B describes symptoms related to possible urinary tract infections or renal issues, but these do not directly indicate overflow incontinence. Choice C, a history of frequent urinary tract infections, may suggest other urinary issues but not specifically overflow incontinence. Choice D, a confused client who forgets to go to the bathroom, is more indicative of functional incontinence rather than overflow incontinence.

4. 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.

5. The client with a mechanical valve replacement understands the discharge teaching when the client makes which statement?

• A. ''I will need to take antibiotics before any type of invasive dental work''
• B. ''I will not have to take any more heart medication since I have a new valve''
• C. ''I will need to have this valve replaced in about 10 years''
• D. ''I should notify my healthcare provider if I hear a clicking sound near my heart''

Correct answer: A

Rationale: The correct answer is A. Clients with mechanical valve replacements need to take prophylactic antibiotics before dental procedures to prevent endocarditis. Choice B is incorrect because even with a new valve, heart medications may still be necessary to manage the condition. Choice C is incorrect because mechanical valves typically do not need replacement as frequently as within 10 years. Choice D is incorrect because hearing a clicking sound near the heart could indicate valve malfunction, not just the need to notify the healthcare provider.

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