Nursing Elites

1. In a client with liver cirrhosis, which symptom would be most concerning during assessment?

• A. Jaundice
• B. Ascites
• C. Hepatomegaly
• D. Altered mental status

Correct answer: D

Rationale: Altered mental status would be the most concerning symptom in a client with liver cirrhosis. It may indicate hepatic encephalopathy, a serious complication requiring immediate intervention. While jaundice, ascites, and hepatomegaly are common in liver cirrhosis, they do not directly correlate with the urgency and severity of hepatic encephalopathy as altered mental status does. Therefore, altered mental status takes priority for immediate attention and intervention.

2. The client is being taught about the use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?

• A. Remove the needle after discarding used syringes
• B. Wear gloves while disposing of the needle and syringe
• C. Wear a face mask during medication administration
• D. Wash hands before handling the needle and syringe

Correct answer: D

Rationale: The correct answer is D. Washing hands before handling the needle and syringe is a critical step in infection control and adherence to standard precautions. Clean hands help prevent the transfer of microorganisms and reduce the risk of infection. Choices A, B, and C do not directly relate to standard precautions. Removing the needle after discarding used syringes (Choice A) can increase the risk of needlestick injuries. Wearing gloves while disposing of the needle and syringe (Choice B) is important for personal protection but does not specifically address standard precautions. Wearing a face mask during medication administration (Choice C) is not directly related to handling syringes and needles, which are more pertinent to standard precautions.

3. What action should the nurse include in the plan of care for a postoperative client with a history of poor nutritional intake who needs care for wound healing?

• A. Provide a protein intake of 1.5 g/kg of body weight per day.
• B. Increase carbohydrate intake to 50% of daily calories.
• C. Administer high-dose vitamin supplements.
• D. Ensure a daily intake of 1000 calories.

Correct answer: A

Rationale: To promote wound healing in a postoperative client with poor nutritional intake, the nurse should include a protein intake of 1.5 g/kg of body weight per day in the plan of care. Proteins are essential for tissue repair and wound healing. Increasing carbohydrate intake or administering high-dose vitamin supplements may not directly promote wound healing. Ensuring a daily intake of 1000 calories may not provide adequate nutrients for optimal wound healing.

4. While bathing a patient, the nurse notices movement in the patient's hair. What action should the nurse take?

• A. Use gloves to inspect the hair.
• B. Apply a lindane-based shampoo immediately.
• C. Shave the patient's hair off.
• D. Ignore the movement and continue.

Correct answer: A

Rationale: When a nurse suspects pediculosis capitis (head lice) upon noticing movement in the patient's hair, the correct action is to use gloves to inspect the hair. This protects the nurse from potential self-infestations. Applying a lindane-based shampoo immediately (Choice B) is not the first action, as diagnosis and confirmation are necessary before treatment. Shaving the patient's hair off (Choice C) is an extreme measure and is unnecessary at this stage. Ignoring the movement and continuing (Choice D) is negligent and can lead to the spread of infestation.

5. A client is scheduled for an appendectomy and has given informed consent. Which statement by the client should the nurse address first preoperatively?

• A. “I am afraid to walk if it hurts too much.”
• B. “I don’t understand why I need this surgery.”
• C. “I don’t want my family helping me after the surgery.”
• D. “I am afraid the scar will make me look disfigured.”

Correct answer: B

Rationale: The nurse should address the client's lack of understanding regarding the need for surgery first. Ensuring that the client comprehends the rationale for the procedure is essential for informed consent. Choices A, C, and D, while important, do not directly impact the client's understanding of the necessity of the surgery and can be addressed after clarifying the reason for the procedure.

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