Nursing Elites

1. A client with cirrhosis is taking lactulose (Cephulac). Which finding indicates that the lactulose is having the desired effect?

• A. Two to three soft bowel movements per day
• B. Increased serum ammonia levels
• C. Decreased white blood cell count
• D. Soft, formed stool twice a day

Correct answer: A

Rationale: The correct answer is A: 'Two to three soft bowel movements per day.' Lactulose is prescribed to produce soft, regular bowel movements to reduce ammonia levels in clients with cirrhosis. This helps in preventing hepatic encephalopathy. Option B is incorrect because increased serum ammonia levels would indicate that lactulose is not effectively reducing ammonia levels. Option C is incorrect because lactulose does not directly affect white blood cell counts. Option D is incorrect because soft, formed stools twice a day may not be frequent enough to effectively reduce ammonia levels in clients with cirrhosis.

2. The nurse is preparing to administer an IM dose of vitamin B1 (Thiamine) to a male client experiencing acute alcohol withdrawal and peripheral neuritis. The client belligerently states, 'What do you think you're doing?' How should the nurse respond?

• A. I cannot give you this medication until you calm down.
• B. This shot will help relieve the pain in your feet.
• C. Would you prefer to learn to administer your own shot?
• D. You will feel calmer and less jittery after this shot.

Correct answer: B

Rationale: Choice B is the correct answer because it addresses the client's concern by explaining that the shot will help relieve the pain in his feet, which is a symptom of peripheral neuritis. This response shows empathy and provides the client with a clear benefit of receiving the medication. Choices A, C, and D do not directly address the client's immediate concern about the injection and its purpose, making them less suitable responses. Choice A focuses on the client's behavior rather than the therapeutic effect of the injection. Choice C shifts the responsibility to the client to administer the shot, which may not be appropriate in this situation. Choice D mentions feeling calmer and less jittery, which is not directly related to the client's current complaint of pain in the feet.

3. A client with a history of congestive heart failure (CHF) is admitted with fluid volume overload. Which assessment finding should the nurse report to the healthcare provider?

• A. Weight gain of 2 pounds in 24 hours
• B. Presence of a cough
• C. Edema in the lower extremities
• D. Shortness of breath

Correct answer: D

Rationale: The correct answer is 'D - Shortness of breath.' In a client with congestive heart failure experiencing fluid volume overload, shortness of breath is a critical finding that indicates possible pulmonary congestion and worsening heart failure. This symptom requires immediate attention to prevent further complications. Choices A, B, and C are common findings in clients with CHF but are not as urgent as shortness of breath. Weight gain may indicate fluid retention, cough can be due to pulmonary congestion, and edema in lower extremities is a common manifestation of CHF, but none of these findings are as concerning as shortness of breath in this scenario.

4. A male client with hypertension tells the nurse that he is going to take ginseng to increase his stamina. What information should the nurse provide this client?

• A. Ginseng can decrease the effectiveness of your blood pressure medication
• B. You will need to stop taking ginseng while on blood pressure medication
• C. It is important to monitor your blood pressure regularly while taking ginseng
• D. Ginseng can increase your blood pressure

Correct answer: D

Rationale: The correct answer is D: "Ginseng can increase blood pressure, which is a concern for clients with hypertension." Choice A is incorrect because ginseng does not typically decrease the effectiveness of blood pressure medication. Choice B is incorrect as stopping ginseng while on blood pressure medication may not be necessary. Choice C is not the most direct concern related to ginseng use in a hypertensive client, making it less relevant than the correct answer.

5. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who has a respiratory rate of 32 breaths/min and a heart rate of 110 beats/min. What action should the nurse take first?

• A. Administer a bronchodilator
• B. Encourage deep breathing and coughing
• C. Assess the client's oxygen saturation level
• D. Obtain an arterial blood gas

Correct answer: C

Rationale: The correct action for the nurse to take first is to assess the client's oxygen saturation level. In a client with COPD and abnormal respiratory and heart rates, determining the oxygen saturation helps evaluate the adequacy of oxygen exchange and the severity of respiratory distress. Administering a bronchodilator (choice A) can be appropriate but assessing oxygen saturation takes priority. Encouraging deep breathing and coughing (choice B) may not address the immediate need for oxygenation assessment. Obtaining an arterial blood gas (choice D) is important but typically follows the initial assessment of oxygen saturation.

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