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 client is recovering from a hip replacement and is taking Tylenol #3 every 3 hours for pain. In checking the client, which finding suggests a side effect of the analgesic?

• A. Bruising at the operative site
• B. Elevated heart rate
• C. Decreased platelet count
• D. No bowel movement for 3 days

Correct answer: D

Rationale: The correct answer is D. Constipation is a common side effect of Tylenol #3, which contains codeine. Codeine can slow down bowel movements, leading to constipation. Monitoring for constipation and implementing management strategies is crucial. Choices A, B, and C are incorrect because bruising at the operative site, elevated heart rate, and decreased platelet count are not commonly associated side effects of Tylenol #3.

3. The nurse assesses a 72-year-old client who was admitted for right-sided congestive heart failure. Which of the following would the nurse anticipate finding?

• A. Decreased urinary output
• B. Jugular vein distention
• C. Pleural effusion
• D. Bibasilar crackles

Correct answer: B

Rationale: In right-sided congestive heart failure, the nurse would anticipate finding jugular vein distention. This occurs due to increased venous pressure, leading to the distention of the jugular veins in the neck. Choices A, C, and D are incorrect. Decreased urinary output is not typically associated with right-sided heart failure; pleural effusion and bibasilar crackles are more commonly seen in conditions like left-sided heart failure.

4. Why is it important for the healthcare provider to monitor blood pressure in clients receiving antipsychotic drugs?

• A. Orthostatic hypotension is a common side effect.
• B. Most antipsychotic drugs cause elevated blood pressure.
• C. This provides information on the amount of sodium allowed in the diet.
• D. It will indicate the need to institute anti-parkinsonian drugs.

Correct answer: A

Rationale: The correct answer is A because monitoring for orthostatic hypotension is crucial when clients are receiving antipsychotic drugs since it is a common side effect. Orthostatic hypotension can lead to symptoms like dizziness and falls, making it essential to monitor blood pressure regularly. Choices B, C, and D are incorrect because most antipsychotic drugs do not typically cause elevated blood pressure, monitoring blood pressure is not directly related to the amount of sodium in the diet, and blood pressure monitoring is not primarily used to determine the need for anti-parkinsonian drugs in clients receiving antipsychotic medications.

5. A client with hypertension taking a potassium-wasting diuretic is being educated about nutrition by a nurse. Which of the following dietary instructions should the nurse include in the teaching?

• A. Increase consumption of tuna and salmon.
• B. Limit intake of dried fruits.
• C. Avoid cow's milk.
• D. Consume organs and bananas

Correct answer: D

Rationale: The correct answer is D: 'Consume organs and bananas.' When a client is taking a potassium-wasting diuretic, they are at risk of potassium loss. Consuming foods high in potassium, such as organs and bananas, can help counteract this loss. Choice A is incorrect because tuna and salmon are not particularly high in potassium. Choice B is incorrect because dried fruits are good sources of potassium. Choice C is incorrect as cow's milk is also a good source of potassium, which could be beneficial for a client taking a potassium-wasting diuretic.

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