Nursing Elites

1. A client is admitted with hepatitis A (HAV) and dehydration. Subjective symptoms include anorexia, fatigue, and malaise. What additional assessment should the nurse expect to find during the preicteric phase?

• A. RUQ abdominal pain
• B. Clay-colored stools
• C. Icteric sclera
• D. Pruritus

Correct answer: A

Rationale: During the preicteric phase of hepatitis A, the nurse should expect to find RUQ (right upper quadrant) abdominal pain. This pain is common in the early phase of hepatitis A and is associated with liver inflammation. Clay-colored stools (Choice B) are typically seen in the icteric phase when there is a lack of bile flow. Icteric sclera (Choice C) refers to yellowing of the eyes, which is a characteristic of the icteric phase. Pruritus (Choice D), which is itching of the skin, is also more commonly associated with the icteric phase when bile salts accumulate in the skin.

2. A client who is scheduled to have surgery in two hours tells the nurse, 'My doctor was here and used a lot of big words about the surgery, then asked me to sign a paper.' What action should the nurse take?

• A. Reassure the client that pre-surgery anxiety is a normal experience
• B. Explain the surgery in clear terms that the client can understand
• C. Call the surgeon back to clarify the information with the client
• D. Redirect the client’s thoughts by teaching relaxation techniques

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is to explain the surgery to the client in clear terms that they can understand. This will help alleviate the client's anxiety and ensure they are well-informed about the procedure they are about to undergo. Choice A is incorrect because while reassurance is important, it does not address the client's specific concern about understanding the surgery. Choice C is not the initial step; the nurse should first attempt to clarify the information themselves. Choice D is not the priority when the client is seeking clarification about the surgery.

3. What should the nurse monitor for during the IV infusion of vasopressin (Pitressin) in a client with bleeding esophageal varices?

• A. Vasodilatation of the extremities
• B. Chest pain and dysrhythmia
• C. Hypotension and tachycardia
• D. Decreasing GI cramping and nausea

Correct answer: B

Rationale: During the IV infusion of vasopressin in a client with bleeding esophageal varices, the nurse should monitor for chest pain and dysrhythmia. Vasopressin is a vasoconstrictor that can cause cardiovascular effects, including chest pain and dysrhythmias. Options A, C, and D are incorrect as vasopressin is not expected to cause vasodilatation of the extremities, hypotension, tachycardia, or improvements in GI symptoms such as cramping and nausea.

4. An adult male with a 6 cm thoracic aneurysm is being prepared for surgery. The nurse reports to the healthcare provider that the client’s blood pressure is 220/112 mmHg, so an antihypertensive agent is added to the client’s IV infusion. Which finding warrants immediate intervention by the nurse?

• A. Reports a tearing, sharp pain between his shoulder blades
• B. Blood pressure reading of 200/100 mmHg 15 minutes later
• C. Rose-colored urine draining from the urinary catheter
• D. Sinus tachycardia with frequent premature ventricular beats (PVC)

Correct answer: A

Rationale: A tearing, sharp pain between the shoulder blades may indicate aortic dissection, a serious complication requiring immediate intervention. This symptom is highly concerning in a patient with a thoracic aneurysm. Choice B is not as urgent as the pain symptom described in choice A. Choice C could indicate hematuria but is not as critical as the potential aortic dissection in choice A. Choice D, sinus tachycardia with PVCs, may be related to the patient's condition but is not as indicative of an immediate life-threatening situation as the tearing, sharp pain indicative of aortic dissection.

5. The nurse is teaching a male adolescent recently diagnosed with type 1 diabetes mellitus (DM) about self-injecting insulin. Which approach is best for the nurse to use to evaluate the effectiveness of the teaching?

• A. Observe him demonstrating the self-injection technique to another diabetic adolescent.
• B. Ask the adolescent to describe his comfort level with injecting himself with insulin.
• C. Review his glycosylated hemoglobin level 3 months after the teaching session.
• D. Have the adolescent list the steps for safe insulin administration.

Correct answer: C

Rationale: Reviewing the glycosylated hemoglobin level after a few months is the best approach to evaluate the effectiveness of teaching self-injection. This measurement provides an objective indicator of the adolescent's glucose control over time, reflecting the impact of insulin self-administration education. Choices A, B, and D do not directly assess the long-term impact of the teaching on the adolescent's diabetes management.

Similar Questions