Nursing Elites

1. What nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction?

• A. Presence of blood in stools
• B. Oozing liquid stool
• C. Continuous rumbling flatulence
• D. Absence of bowel movements

Correct answer: B

Rationale: The correct answer is B: 'Oozing liquid stool.' In a paralyzed client, oozing liquid stool is a common sign of fecal impaction. This occurrence requires prompt intervention to prevent complications. Choice A, 'Presence of blood in stools,' is more indicative of gastrointestinal bleeding rather than fecal impaction. Choice C, 'Continuous rumbling flatulence,' is associated with gas movement in the intestines and not specifically linked to fecal impaction. Choice D, 'Absence of bowel movements,' could be a sign of constipation but does not directly point towards fecal impaction.

2. A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) 4 hours ago. Labor is to be induced. At the time of the ROM the vital signs were T-99.8 degrees F, P-84, R-20, BP-130/78, and fetal heart tones (FHT) 148 beats/min. Which assessment findings taken now may be an early indication that the client is developing a complication of labor?

• A. FHT 168 beats/min
• B. Temperature 100 degrees Fahrenheit
• C. Cervical dilation of 4 cm
• D. BP 138/88

Correct answer: A

Rationale: The correct answer is A. Fetal heart rate elevation can indicate distress, making it an early sign of labor complications. Choices B, C, and D are not the best answers in this scenario. Choice B, an elevated temperature, could indicate infection but is not a direct sign of labor complications. Choice C, cervical dilation of 4 cm, is a normal part of labor progression for a primigravida. Choice D, a blood pressure of 138/88, falls within normal limits and is not an early indication of labor complications.

3. Although non-steroidal anti-inflammatory drugs such as ibuprofen (Motrin) are beneficial in managing arthritis pain, the nurse should caution clients about which of the following common side effects?

• A. Urinary incontinence
• B. Constipation
• C. Nystagmus
• D. Occult bleeding

Correct answer: D

Rationale: The correct answer is D: Occult bleeding. Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen are known to cause gastrointestinal side effects, including occult bleeding. Occult bleeding refers to bleeding in the gastrointestinal tract that may not be visible in the stool, leading to potential complications like anemia. Urinary incontinence (choice A) is not a common side effect of NSAIDs. Constipation (choice B) is also not a typical side effect associated with NSAIDs. Nystagmus (choice C) is an involuntary eye movement and is not a common side effect of NSAIDs. Therefore, the nurse should caution clients about the risk of occult bleeding when using NSAIDs for arthritis pain management.

4. The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately?

• A. Blood urea nitrogen 50 mg/dl
• B. Hemoglobin of 10.3 g/dl
• C. Venous blood pH 7.30
• D. Serum potassium 6 mEq/L

Correct answer: D

Rationale: A serum potassium level of 6 mEq/L indicates hyperkalemia, which can be life-threatening and requires immediate intervention. Hyperkalemia can lead to dangerous cardiac arrhythmias and must be addressed promptly. The other options are not as urgent. A blood urea nitrogen level of 50 mg/dl may indicate kidney dysfunction but does not require immediate intervention. Hemoglobin of 10.3 g/dl may suggest anemia, which needs management but is not an immediate threat. A venous blood pH of 7.30 may indicate acidosis, which is concerning but not as acutely dangerous as hyperkalemia.

5. A nurse is caring for a client who has a new prescription for a low-sodium diet. The client's family has requested to bring in some of the client's favorite foods. Which of the following food items should the nurse recommend the family members to omit?

• A. Boiled rice
• B. Italian bread
• C. Broiled salmon filet
• D. Pickled beets

Correct answer: D

Rationale: The correct answer is D, Pickled beets. Pickled foods often contain high levels of sodium, which should be avoided in a low-sodium diet. Boiled rice, Italian bread, and broiled salmon filet are generally lower in sodium compared to pickled beets, making them more suitable choices for a client on a low-sodium diet.

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