Nursing Elites

1. A client is admitted to a medical unit with the diagnosis of gastritis and chronic heavy alcohol abuse. What should the nurse administer to prevent the development of Wernicke's syndrome?

• A. Lorazepam (Ativan)
• B. Famotidine (Pepcid)
• C. Thiamine (Vitamin B1)
• D. Atenolol (Tenormin)

Correct answer: C

Rationale: Thiamine supplementation is critical in preventing Wernicke's syndrome, especially in clients with chronic alcohol use. Wernicke's syndrome is a neurological disorder caused by thiamine deficiency. Lorazepam is a benzodiazepine used for anxiety and not for preventing Wernicke's syndrome. Famotidine is an H2 blocker used to reduce stomach acid production but does not prevent Wernicke's syndrome. Atenolol is a beta-blocker used for hypertension and angina, not for preventing Wernicke's syndrome.

2. When assessing a mildly obese 35-year-old female client, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. What is the most likely explanation for the failure to locate the gallbladder by palpation?

• A. The client is too obese.
• B. Palpating in the wrong location.
• C. The gallbladder is normal.
• D. Deeper palpation technique is needed.

Correct answer: A

Rationale: The correct answer is A. Obesity can make it difficult to palpate the gallbladder due to increased abdominal tissue, making it challenging to locate specific structures. Choice B is incorrect because the nurse is palpating in the correct location below the liver margin at the lateral border of the rectus abdominal muscle, where the gallbladder is typically located. Choice C is incorrect as the inability to palpate the gallbladder does not necessarily indicate abnormality; it may be due to anatomical variations or technical challenges. Choice D is incorrect as the issue lies more with the difficulty posed by excess adipose tissue rather than the need for deeper palpation techniques.

3. A client with multiple sclerosis is receiving baclofen 15 mg PO three times daily. The drug is available in 10 mg tablets. How many tablets should the nurse administer in a 24-hour period? (Enter a numeric value only. If rounding is required, round to the nearest tenth)

• A. 4.5
• B.
• C.
• D.

Correct answer: A

Rationale: To calculate the total dose of baclofen needed in a 24-hour period, multiply 15 mg by 3 doses, which equals 45 mg. Since the tablets are available in 10 mg strength, divide the total dose needed (45 mg) by the strength of each tablet (10 mg), which equals 4.5 tablets. Rounding off to the nearest tenth, the nurse should administer 4.5 tablets of 10 mg baclofen per day. Therefore, choice A is correct. Choices B, C, and D are irrelevant as they are not provided.

4. A postoperative client returns to the nursing unit following a ureterolithotomy via a flank incision. Which potential nursing problem has the highest priority when planning nursing care for this client?

• A. Ineffective airway clearance
• B. Altered nutrition less than body requirements
• C. Fluid volume excess
• D. Activity intolerance

Correct answer: A

Rationale: In this scenario, the highest priority nursing problem for the postoperative client following a ureterolithotomy via a flank incision is ineffective airway clearance. After surgery, there is a risk of airway obstruction due to factors like anesthesia, positioning during surgery, or the presence of secretions. Maintaining a clear airway is crucial to prevent respiratory complications, such as atelectasis or pneumonia. Altered nutrition, fluid volume excess, and activity intolerance are important considerations but are secondary to the immediate threat of compromised airway clearance in the postoperative period.

5. A woman with an anxiety disorder calls her obstetrician’s office and tells the nurse of increased anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her antianxiety medications, but thinks she may need to start taking them again because of her increased anxiety. What response is best for the nurse to provide this woman?

• A. Describe the safety of certain antianxiety medications during breastfeeding
• B. Encourage her to consider stress-relieving alternatives, such as deep breathing exercises
• C. Inform her that some antianxiety medications are safe to take while breastfeeding
• D. Explain that anxiety is a common response for the mother of a 3-week-old

Correct answer: C

Rationale: The correct answer is C. Some antianxiety medications are considered safe for use while breastfeeding, and the nurse should provide this information to alleviate the woman's concerns. Choice A has been corrected to focus on the safety of certain antianxiety medications during breastfeeding, which is more accurate. Choice B suggests stress-relieving alternatives, which may help but do not address the need for antianxiety medication if required. Choice D is incorrect because it minimizes the woman's concerns by dismissing her increased anxiety as a normal response.

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