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 with a history of myocardial infarction (MI) is receiving a beta-blocker medication. What is the most important outcome for the nurse to monitor?

• A. Heart rate and blood pressure
• B. Blood glucose levels
• C. Respiratory rate
• D. Liver function tests

Correct answer: A

Rationale: The correct answer is A: Heart rate and blood pressure. When a client with a history of myocardial infarction (MI) is on a beta-blocker medication, monitoring heart rate and blood pressure is crucial. Beta-blockers lower heart rate and blood pressure, so monitoring these parameters helps assess the medication's effectiveness and prevent complications like bradycardia or hypotension. Choices B, C, and D are not the most important outcomes to monitor in this scenario. Blood glucose levels are typically monitored in clients with diabetes or when using medications that affect glucose levels. Respiratory rate is important in assessing respiratory function and oxygenation, while liver function tests are more relevant when monitoring the impact of medications on liver health.

3. The nurse is making assignments for a new graduate from a practical nursing program who is orienting to the unit. Because the unit is particularly busy this day, there will be little time to provide supervision of this new employee. Which client is the best for the nurse to assign this newly graduate practical nurse? A client

• A. Whose discharge has been delayed because of a postoperative infection
• B. With poorly controlled type 2 diabetes who is on a sliding scale for insulin administration
• C. Newly admitted with a head injury who requires frequent assessments
• D. Who is receiving IV heparin that is regulated based on protocol

Correct answer: A

Rationale: The correct answer is option A because this client is the most stable and requires less supervision. Assigning a client whose discharge has been delayed due to a postoperative infection to the newly graduate practical nurse would be appropriate during a busy day as they are likely to need routine care and monitoring rather than immediate intensive interventions. Option B involves a client with poorly controlled type 2 diabetes on a sliding scale for insulin administration, which requires close monitoring and prompt intervention, making it a less suitable assignment for a new graduate who may need more guidance. Option C, a newly admitted patient with a head injury requiring frequent assessments, would demand a higher level of vigilance and expertise, which may be challenging for a new graduate nurse to handle without adequate supervision. Option D, a patient receiving IV heparin regulated based on protocol, involves complex medication management that may be too advanced for a new graduate nurse without sufficient oversight.

4. What instruction should the nurse provide a pregnant client experiencing heartburn?

• A. Limit fluid intake between meals to prevent stomach over-distension
• B. Take an antacid at bedtime and when symptoms worsen
• C. Maintain an upright position for two hours after eating
• D. Eat small meals throughout the day to avoid a full stomach

Correct answer: D

Rationale: The correct answer is D: 'Eat small meals throughout the day to avoid a full stomach.' Heartburn is common in pregnancy due to increased intra-abdominal pressure and hormonal changes. Consuming small, frequent meals prevents the stomach from becoming overly full, reducing the likelihood of acid reflux and heartburn. Choice A is incorrect because limiting fluid intake between meals may not significantly impact heartburn. Choice B is not ideal as antacids should be taken as directed by a healthcare provider, not just at bedtime or when symptoms worsen. Choice C is less effective advice, as maintaining an upright position after eating may not directly address the root cause of heartburn.

5. The nurse is caring for a newborn who arrives in the nursery following a precipitous birth on the way to the hospital. A drug screen of the mother reveals the presence of cocaine metabolites. The infant has a heart rate of 175 beats/minute, cries continuously, is irritable, and is hyperreactive to stimuli. Which intervention is most important for the nurse to include in this infant’s plan of care?

• A. Initiate infant sepsis protocol
• B. Implement seizure precautions
• C. Refer to protective child services
• D. Formula feed every 3 hours

Correct answer: B

Rationale: The infant's symptoms, such as a high heart rate, continuous crying, irritability, and hyperreactivity, suggest possible withdrawal effects due to maternal cocaine use. These symptoms can lead to seizures. Therefore, the priority intervention is to implement seizure precautions to ensure the infant's safety. Initiating the infant sepsis protocol is not indicated based on the symptoms presented. Referring to protective child services is important but not the immediate priority. Formula feeding every 3 hours is a routine care measure but does not address the urgent need to prevent potential seizures.

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