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. After successful resuscitation, a client is given propranolol and transferred to the Intensive Coronary Care Unit (ICCU). On admission, magnesium sulfate 4 grams IV in 250 ml D5W at one gram/hour. Which assessment findings require immediate intervention by the nurse?

• A. Dark amber urine draining via an indwelling catheter at a rate of 40 ml per hour
• B. Serum calcium of 9.0 mg/dl (2.2 mmol/L SI) and magnesium of 1.8 mg/dl or Eq/L (0.74 mmol/L SI)
• C. Sinus rhythm at 72 beats/minute and peripheral blood pressure of 99/62
• D. Respiratory rate of 10 breaths per minute

Correct answer: D

Rationale: The correct answer is D. A low respiratory rate of 10 breaths per minute is indicative of possible magnesium toxicity, which can be a serious condition requiring immediate intervention. It is a critical finding that needs prompt attention to prevent further complications. The other options are not as urgent: A - dark amber urine may indicate dehydration but does not require immediate intervention, B - serum calcium and magnesium levels are within normal limits, C - sinus rhythm and blood pressure values are also within normal range and do not require immediate action.

3. A 41-week gestation primigravida woman is admitted to labor and delivery for induction of labor. What finding should the nurse report to the healthcare provider before initiating the infusion of oxytocin?

• A. Fetal heart tones located in the upper right quadrant
• B. Biophysical profile results showing oligohydramnios
• C. Regular contractions occurring every 10 minutes
• D. Sterile vaginal exam revealing 3 cm dilation

Correct answer: B

Rationale: Oligohydramnios (low amniotic fluid) is a significant concern before starting oxytocin and should be reported to ensure safe labor induction. This finding can indicate potential fetal compromise and requires immediate evaluation. Fetal heart tones located in a specific quadrant, regular contractions, and cervical dilation are common assessments during labor but are not as critical as oligohydramnios in this scenario.

4. When preparing to discharge a male client who has been hospitalized for an adrenal crisis, the client expresses concern about having another crisis. He tells the nurse that he wants to stay in the hospital a few more days. Which intervention should the nurse implement?

• A. Administer antianxiety medication before providing discharge instructions
• B. Schedule a follow-up appointment for an outpatient psychosocial assessment
• C. Obtain a blood cortisol level before discharge
• D. Encourage the client to remain in the hospital for a few more days

Correct answer: B

Rationale: The correct intervention is to schedule a follow-up appointment for an outpatient psychosocial assessment. This option addresses the client's concerns and provides support for managing stress and preventing future crises, which is crucial for the client's long-term care. Administering antianxiety medication before providing discharge instructions (Choice A) may not effectively address the underlying concerns. Obtaining a blood cortisol level before discharge (Choice C) is important but not the priority in this situation. Encouraging the client to remain in the hospital for a few more days (Choice D) is not the best course of action as it may not address the client's anxiety and could potentially lead to other issues.

5. A 70-year-old client is admitted to the hospital after 24 hours of acute diarrhea. To determine fluid status, which initial data is most important for the nurse to obtain?

• A. Usual and current weight
• B. Color and amount of urine
• C. Number and frequency of stools
• D. Intake and output 24 hours prior to admission

Correct answer: A

Rationale: The correct answer is A: Usual and current weight. Weight changes are the most direct indicator of fluid status in a patient with acute diarrhea. Monitoring weight loss or gain can provide crucial information about fluid balance. Option B, color and amount of urine, though important for assessing renal function, is not as direct an indicator of fluid status as weight. Option C, number and frequency of stools, is relevant for assessing the severity of diarrhea but does not provide direct information on fluid status. Option D, intake and output 24 hours prior to admission, does not reflect the current fluid status and may not be accurate in a rapidly changing condition like acute diarrhea.

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