Nursing Elites

1. The client with chronic alcoholism has chronic pancreatitis and hypomagnesemia. What should the nurse assess when administering magnesium sulfate to the client?

• A. Deep tendon reflexes
• B. Arterial blood gases
• C. Skin turgor
• D. Capillary refill time

Correct answer: A

Rationale: Corrected Rationale: When administering magnesium sulfate to a client with chronic alcoholism, chronic pancreatitis, and hypomagnesemia, the nurse should assess deep tendon reflexes. Magnesium sulfate can depress the central nervous system and decrease deep tendon reflexes, so monitoring them is crucial. Assessing arterial blood gases, skin turgor, or capillary refill time is not directly related to the administration of magnesium sulfate in this scenario.

2. The nurse is caring for the client one day postoperative sigmoid colostomy operation. Which independent nursing intervention should the nurse implement?

• A. Change the infusion rate of the intravenous fluid
• B. Encourage the client to discuss his or her feelings
• C. Administer opioid narcotic medications for pain management
• D. Assist the client out of bed to sit in the chair twice daily

Correct answer: D

Rationale: Assisting the client to sit in a chair is an essential nursing intervention postoperatively as it helps promote circulation, prevent complications like blood clots, and aids in the recovery process. Changing the infusion rate of intravenous fluid (Choice A) requires a physician's order and is not an independent nursing intervention. Encouraging the client to discuss feelings (Choice B) is important for emotional support but not as crucial as physical care immediately postoperatively. Administering opioid narcotic medications (Choice C) for pain management should be based on a prescribed schedule and assessment rather than being an independent nursing action.

3. The nurse in the pediatric clinic performs a physical assessment of a 13-year-old boy. Which of the following findings by the nurse requires immediate intervention?

• A. The adolescent complains of his scrotum aching after exercise. The nurse palpates a worm-like mass above the testes.
• B. The nurse noted unilateral breast enlargement.
• C. The child’s scrotum appears swollen, and a soft mass is palpated. The nurse is unable to insert a finger above the mass.
• D. The child’s scrotum appears enlarged and red. The nurse palpated a thickened and swollen spermatic cord.

Correct answer: D

Rationale: Choice D is the correct answer because a swollen and thickened spermatic cord could indicate testicular torsion, which is a surgical emergency. Testicular torsion occurs when the spermatic cord twists, cutting off the blood supply to the testicle. This condition requires immediate intervention to prevent testicular damage. Choices A, B, and C do not present findings that suggest a surgical emergency requiring immediate intervention.

4. Which potential complication should the nurse assess for in the client with infective endocarditis who has embolization of vegetative lesions from the mitral valve?

• A. Pulmonary embolism
• B. Decreased urine output
• C. Hemoptysis
• D. Deep vein thrombosis

Correct answer: B

Rationale: The correct answer is 'Decreased urine output.' Embolization of vegetative lesions from the mitral valve can cause renal infarction, leading to a decrease in urine output. This complication is due to the obstruction of blood flow to the kidneys. Choices A, C, and D are incorrect because embolization from the mitral valve typically does not directly cause pulmonary embolism, hemoptysis, or deep vein thrombosis.

5. Which type of diet is recommended for patients with diverticulitis during an acute flare-up?

• A. High-fiber
• B. Low-residue
• C. Low-fat
• D. High-protein

Correct answer: B

Rationale: During an acute flare-up of diverticulitis, a low-residue diet is recommended. This diet helps reduce bowel movements and minimizes irritants in the colon, which can help alleviate symptoms and promote healing. High-fiber diets, like choice A, are typically recommended for diverticulosis prevention but may exacerbate symptoms during a flare-up due to increased bulk in the stool. Low-fat (choice C) and high-protein (choice D) diets are not specifically indicated for diverticulitis flare-ups.

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