Nursing Elites

1. What is the first action the nurse should implement for a client admitted with acute pancreatitis?

• A. Administer intravenous fluids as prescribed
• B. Administer pain medication as prescribed
• C. Place the client on NPO status
• D. Assess the client's abdomen for distention

Correct answer: C

Rationale: Placing the client on NPO status is the priority action for a client with acute pancreatitis. This step is crucial to rest the pancreas, prevent pancreatic stimulation, and decrease enzyme production. By withholding oral intake, the digestive system is given a chance to rest and recover. Administering intravenous fluids may be necessary but should come after placing the client on NPO status. Pain medication can be administered once the client is stabilized. Assessing the client's abdomen for distention is important but is not the initial priority in managing acute pancreatitis.

2. When organizing home visits for the day, which older client should the home health nurse plan to visit first?

• A. A woman who takes naproxen (Naprosyn) and reports a recent onset of dark, tarry stools.
• B. A man who receives weekly injections of epoetin (Procrit) for a low serum iron level.
• C. A man with emphysema who smokes and is complaining of white patches in his mouth.
• D. A frail woman with heart failure who reported a 2-pound weight gain in the last week.

Correct answer: A

Rationale: The correct answer is A. Dark, tarry stools may indicate gastrointestinal bleeding, a potentially life-threatening condition that requires immediate attention. Visiting this client first is crucial for prompt assessment and intervention. Choices B, C, and D do not present immediate life-threatening conditions that require urgent attention compared to the potential emergency indicated by dark, tarry stools.

3. A 59-year-old male client comes to the clinic and reports his concern over a lump that 'just popped up on my neck about a week ago.' In performing an examination of the lump, the nurse palpates a large, nontender, hardened left subclavian lymph node. There is no overlying tissue inflammation. What do these findings suggest?

• A. Malignancy
• B. Infection
• C. Benign cyst
• D. Lymphadenitis

Correct answer: A

Rationale: The correct answer is A: Malignancy. A large, non-tender, hardened lymph node is a typical sign of malignancy and warrants further investigation. Choice B (Infection) is incorrect because typically in infections, lymph nodes are tender and may show signs of inflammation. Choice C (Benign cyst) is incorrect as a benign cyst would usually present as a soft, mobile lump. Choice D (Lymphadenitis) is incorrect as lymphadenitis usually presents with tender and enlarged lymph nodes due to inflammation.

4. The nurse is preparing a community education program on osteoporosis. Which instruction is helpful in preventing bone loss and promoting bone formation?

• A. Recommend weight-bearing physical activity.
• B. Encourage a diet high in dairy products.
• C. Suggest vitamin D supplementation.
• D. Advise avoiding caffeine and alcohol.

Correct answer: A

Rationale: The correct answer is A: Recommend weight-bearing physical activity. Weight-bearing exercises are effective in maintaining bone density and preventing osteoporosis by promoting bone formation. Encouraging a diet high in dairy products (choice B) can provide calcium, but it's not as directly related to bone formation as physical activity. While vitamin D supplementation (choice C) is important for calcium absorption and bone health, it is not directly involved in promoting bone formation. Advising to avoid caffeine and alcohol (choice D) can be beneficial for bone health, but it is not as directly related to promoting bone formation as weight-bearing physical activity.

5. The nurse is assessing a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which assessment finding is most concerning?

• A. Increased fatigue
• B. Elevated blood pressure
• C. Low urine output
• D. Elevated hemoglobin

Correct answer: B

Rationale: In a client with chronic kidney disease (CKD) receiving erythropoietin therapy, an elevated blood pressure is the most concerning assessment finding. Elevated blood pressure can indicate worsening hypertension, which requires immediate intervention. Increased fatigue may be expected due to anemia associated with CKD and erythropoietin therapy. Low urine output may indicate impaired kidney function but is not as immediately concerning as elevated blood pressure. Elevated hemoglobin levels are the desired outcome of erythropoietin therapy, indicating an appropriate response to treatment.

Similar Questions