Nursing Elites

1. A client taking clopidogrel reports the onset of diarrhea. Which nursing action should the nurse implement first?

• A. Observe the appearance of the stool
• B. Assess the client’s skin turgor
• C. Review the client’s laboratory values
• D. Auscultate the client’s bowel sounds

Correct answer: A

Rationale: Observing the stool’s appearance should be implemented first as it helps determine the nature and possible severity of the diarrhea, which is essential in managing the side effect. Assessing skin turgor (Choice B) is not the priority in this situation. Reviewing laboratory values (Choice C) can provide additional information but is not the initial step. Auscultating bowel sounds (Choice D) is not the priority when the client is experiencing diarrhea.

2. A male client who fell into the lake while fishing and was submerged for about 3 min was successfully resuscitated by his friends. He was brought to the Emergency Department for evaluation and was admitted for a 24-hour uneventful hospital stay. What follow-up instruction should the nurse give?

• A. Avoid smoke-filled environments
• B. Seek medical care promptly if a fever develops
• C. Increase oral fluids if a cough becomes productive
• D. Schedule frequent rest periods

Correct answer: B

Rationale: After being submerged in water, the client should be instructed to seek medical care promptly if a fever develops since complications may arise later. Choices A, C, and D are not directly related to the potential complications from submersion in water and are therefore incorrect. Avoiding smoke-filled environments, increasing oral fluids for a productive cough, and scheduling frequent rest periods are not the priority concerns in this scenario.

3. A young adult client was admitted 36 hours ago for a head injury that occurred as a result of a motorcycle accident. In the last 4 hours, the client’s urine output has increased to over 200 ml/hour. Before reporting the finding to the healthcare provider, which intervention should the nurse implement?

• A. Obtain capillary blood samples for glucose every 2 hours
• B. Measure oral secretions suctioned during the last 4 hours
• C. Evaluate the urine osmolality and serum osmolality values
• D. Obtain blood pressure and assess for dependent edema

Correct answer: C

Rationale: The correct answer is to evaluate the urine osmolality and serum osmolality values. The increased urine output following a head injury could indicate diabetes insipidus, a condition characterized by excessive urination and extreme thirst. Evaluating osmolality is crucial for diagnosing diabetes insipidus. Choice A is incorrect because obtaining capillary blood samples for glucose every 2 hours is not the priority in this situation. Choice B is irrelevant to the client's current symptom of increased urine output. Choice D is also not the most appropriate intervention as the focus should be on assessing for a potential endocrine issue related to the increased urine output.

4. The nurse is preparing to administer an oral antibiotic to a client with unilateral weakness, ptosis, mouth drooping, and aspiration pneumonia. What is the priority nursing assessment that should be done before administering this medication?

• A. Ask the client about soft food preferences
• B. Auscultate the client’s breath sounds
• C. Obtain and record the client’s vital signs
• D. Determine which side of the body is weak

Correct answer: B

Rationale: The correct answer is to auscultate the client’s breath sounds. Assessing breath sounds is crucial in this scenario as it helps ensure that the client can safely swallow the oral antibiotic without aspirating. Unilateral weakness, ptosis, mouth drooping, and aspiration pneumonia indicate potential swallowing difficulties, making it essential to assess breath sounds for any signs of respiratory issues. Asking about food preferences (choice A) may be relevant later but is not the priority before administering the medication. While obtaining vital signs (choice C) is important, assessing breath sounds takes precedence in this case. Determining which side of the body is weak (choice D) is not the priority assessment before administering the oral antibiotic.

5. A client collapses while showering and is found by the nurse while making rounds. The client is not breathing and does not have a palpable pulse. The nurse obtains the Automated External Defibrillator (AED). What action should the nurse implement next?

• A. Follow the prompts of the AED
• B. Apply the AED pads to the client’s chest
• C. Wipe the client’s chest dry
• D. Move the client from the bathroom

Correct answer: B

Rationale: Applying the AED pads is the immediate next step after obtaining the AED in a cardiac arrest situation. Placing the pads correctly on the client's chest is crucial for the AED to analyze the heart rhythm accurately and deliver a shock if needed. Following the prompts of the AED comes after the pads are in place. Wiping the client's chest dry or moving the client from the bathroom are not priorities at this critical moment and may delay life-saving interventions.

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