Nursing Elites

1. A client with a small bowel obstruction is experiencing frequent vomiting. Which instructions are most important for the nurse to provide to the unlicensed assistive personnel (UAP) who is completing morning care for this client?

• A. Maintain a quiet environment
• B. Ensure the linens are clean and dry
• C. Place an air deodorizer in the room
• D. Measure all emesis accurately

Correct answer: D

Rationale: The correct answer is D, 'Measure all emesis accurately.' When a client with a small bowel obstruction is experiencing frequent vomiting, measuring emesis accurately is crucial for monitoring fluid balance and preventing dehydration. Choice A, 'Maintain a quiet environment,' while important for patient comfort, is not as critical as accurately measuring emesis. Choices B and C, 'Ensure the linens are clean and dry' and 'Place an air deodorizer in the room,' focus on environmental factors that, although helpful, are not as essential as monitoring the client's fluid balance in this situation.

2. The nurse is planning care for a client who is receiving phenytoin (Dilantin) for seizure control. Which intervention is most important to include in this client’s plan of care?

• A. Monitor serum calcium levels
• B. Obtain a baseline electrocardiogram
• C. Implement seizure precautions
• D. Encourage a low-protein diet

Correct answer: C

Rationale: The correct answer is to implement seizure precautions. Phenytoin is an antiepileptic medication used for seizure control. Seizure precautions are crucial for clients taking this medication to ensure their safety during a seizure episode. Monitoring serum calcium levels (Choice A) is not directly related to phenytoin therapy. Obtaining a baseline electrocardiogram (Choice B) is important for some medications but not the priority for a client on phenytoin. Encouraging a low-protein diet (Choice D) is not specifically indicated for clients on phenytoin and is not the most important intervention.

3. Which action should the nurse include in the plan of care for a client who is receiving acyclovir (Zovirax) IV for the treatment of herpes zoster (shingles)?

• A. Initiate cardiac telemetry monitoring
• B. Maintain continuous pulse oximetry
• C. Perform capillary glucose measurements
• D. Monitor serum creatinine levels

Correct answer: D

Rationale: The correct answer is to monitor serum creatinine levels. Acyclovir can potentially impact kidney function, making it essential to monitor serum creatinine levels to assess renal function. Option A, initiating cardiac telemetry monitoring, is not directly related to acyclovir administration for herpes zoster. Option B, maintaining continuous pulse oximetry, is more relevant in assessing respiratory status rather than monitoring for acyclovir-related side effects. Option C, performing capillary glucose measurements, is not directly associated with acyclovir therapy for herpes zoster.

4. Which nursing diagnosis has the highest priority when planning care for a client in cardiogenic shock?

• A. Risk for imbalanced body temperature
• B. Excess fluid volume
• C. Fatigue
• D. Ineffective Tissue Perfusion

Correct answer: D

Rationale: In cardiogenic shock, the priority nursing diagnosis is Ineffective Tissue Perfusion. This diagnosis indicates that the client is not receiving adequate oxygenated blood to tissues, putting vital organs at risk. Addressing ineffective tissue perfusion is crucial to prevent organ damage and ensure the client's survival. The other options, such as 'Risk for imbalanced body temperature,' 'Excess fluid volume,' and 'Fatigue,' are important but secondary to the immediate threat of inadequate tissue perfusion in cardiogenic shock.

5. A client who has a flaccid bladder is placed on a bladder training program. Which instruction should the nurse include in this client's teaching plan?

• A. Use manual pressure to express urine
• B. Perform the Crede maneuver
• C. Apply an external urinary drainage device
• D. Take a warm sitz bath twice a day

Correct answer: B

Rationale: The correct answer is B: Perform the Crede maneuver. The Crede maneuver is a technique used to manage a flaccid bladder by applying manual pressure over the bladder area to assist in the expulsion of urine. This technique helps promote bladder emptying. Choice A is incorrect because using manual pressure to express urine is not a standardized technique and may cause harm. Choice C is incorrect as applying an external urinary drainage device does not address the need for bladder training. Choice D is unrelated to bladder training for a flaccid bladder.

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