Nursing Elites

1. A client who was discharged 8 months ago with cirrhosis and ascites is admitted with anorexia and recent hemoptysis. The client is drowsy but responds to verbal stimuli. The nurse programs a blood pressure monitor to take readings every 15 minutes. Which assessment should the nurse implement first?

• A. Evaluate distal capillary refill for delayed perfusion
• B. Check the extremities for bruising and petechiae
• C. Examine the peritibial regions for pitting edema
• D. Palpate the abdomen for tenderness and rigidity

Correct answer: D

Rationale: In a client with a history of cirrhosis and ascites presenting with anorexia and recent hemoptysis, palpating the abdomen for tenderness and rigidity is crucial as it helps in identifying signs of complications related to these conditions. Assessing for abdominal tenderness and rigidity can provide valuable information about the presence of internal bleeding, ascites complications, or liver enlargement. Evaluating distal capillary refill, checking for bruising and petechiae, or examining peritibial regions for pitting edema are important assessments but are not the priority in this case, given the client's history and current symptoms.

2. The nurse determines that an adult client who is admitted to the post-anesthesia care unit (PACU) following abdominal surgery has a tympanic temperature of 94.6°F (34.4°C), a pulse rate of 88 beats/minute, a respiratory rate of 14 breaths/minute, and a blood pressure of 94/68 mmHg. Which action should the nurse implement?

• A. Check the BP every five minutes for one hour.
• B. Raise the HOB 60 to 90 degrees.
• C. Ask the client to cough and deep breathe.
• D. Take the client’s temperature using another method.

Correct answer: D

Rationale: Taking the temperature using another method is essential in this situation to verify if the low reading is accurate and requires further intervention. The tympanic temperature of 94.6°F may be inaccurate due to various factors such as improper technique or environmental conditions. Checking the blood pressure every five minutes for one hour (Choice A) is not the priority in this case as the low blood pressure reading alone does not necessitate such frequent monitoring. Raising the head of the bed 60 to 90 degrees (Choice B) is not directly related to addressing the low temperature and blood pressure. Asking the client to cough and deep breathe (Choice C) is a general intervention that may not directly address the specific concern of the low temperature reading.

3. A client is receiving a secondary infusion of erythromycin 1 gram in 100 mL dextrose 5% in water (D5W) to be infused in 45 minutes. How many mL/hour should the nurse program the infusion pump?

• A. 100 mL/hour.
• B. 125 mL/hour.
• C. 133 mL/hour.
• D. 150 mL/hour.

Correct answer: C

Rationale: To infuse 100 mL in 45 minutes, the infusion rate should be set to 133 mL/hour (100 mL / 0.75 hours). This calculation is obtained by dividing the total volume to be infused by the total time for infusion (100 mL / 0.75 hours = 133 mL/hour). Therefore, choice C is the correct answer. Choices A, B, and D are incorrect because they do not accurately calculate the infusion rate required to deliver the medication within the specified time frame.

4. During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?

• A. An old friend with eczema came for a visit.
• B. Recently received an influenza immunization.
• C. A grandson and his new dog recently visited.
• D. Corticosteroid cream was applied to eczema.

Correct answer: C

Rationale: The correct answer is C. Contact with the grandson's new dog could have introduced new allergens or irritants, exacerbating the eczema symptoms. Choice A is unrelated to the exacerbation of symptoms. Choice B, receiving an influenza immunization, is unlikely to directly cause an exacerbation of eczema symptoms. Choice D, applying corticosteroid cream, is a common treatment for eczema and would not likely be the cause of the exacerbation.

5. The nurse is teaching a client about coronary artery disease (CAD) preventive health. Which behavior stated by the client indicates a need for additional information and teaching?

• A. Increasing physical activity.
• B. Eating a low-fat diet.
• C. Decreasing the number of cigarettes smoked per day.
• D. Monitoring blood pressure regularly.

Correct answer: C

Rationale: The correct answer is C. Decreasing the number of cigarettes smoked per day is not sufficient for CAD prevention. Smoking cessation is crucial in reducing the risk of CAD. While increasing physical activity, eating a low-fat diet, and monitoring blood pressure regularly are all positive behaviors for CAD prevention, quitting smoking should be emphasized due to its significant impact on cardiovascular health.

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