Nursing Elites

1. A client with Crohn's disease reports diarrhea. What intervention should the nurse implement?

• A. Instruct the client to drink clear fluids and avoid solid foods.
• B. Administer antidiarrheal medication as prescribed.
• C. Encourage a high-fiber diet and regular physical activity.
• D. Restrict fluid intake and monitor electrolytes.

Correct answer: C

Rationale: The correct intervention for a client with Crohn's disease reporting diarrhea is to encourage a high-fiber diet and regular physical activity. A high-fiber diet helps manage diarrhea in Crohn's disease by adding bulk to the stool and promoting more regular bowel movements. Instructing the client to drink clear fluids and avoid solid foods (Choice A) may not be appropriate as it can further exacerbate diarrhea. Administering antidiarrheal medication (Choice B) without addressing the underlying cause may not be the best initial approach. Encouraging a high-fiber diet and physical activity (Choice C) is beneficial for managing symptoms. Restricting fluid intake and monitoring electrolytes (Choice D) is not recommended as it can lead to dehydration, which is a concern in clients with diarrhea.

2. A client with acute pancreatitis is prescribed nothing by mouth (NPO). What should the nurse prioritize in this client's care?

• A. Administer oral pain medication.
• B. Monitor the client's intake and output.
• C. Monitor the client for signs of infection.
• D. Insert a nasogastric tube for decompression.

Correct answer: B

Rationale: The correct answer is B: Monitor the client's intake and output. When a client with acute pancreatitis is prescribed nothing by mouth (NPO), the nurse should prioritize monitoring the client's intake and output. This is crucial for assessing the client's fluid balance and ensuring that they are not becoming dehydrated or developing complications related to fluid status. Option A is incorrect because oral pain medication should not be administered to a client who is NPO. Option C is not the priority at this time, although monitoring for infection is important in the overall care of the client. Option D is not the initial priority unless there are specific indications for decompression, which would be determined by the healthcare provider.

3. A client with lung cancer is admitted to palliative care. What is the nurse's priority assessment?

• A. Monitor respiratory status and oxygenation.
• B. Evaluate the client's mental status and cognition.
• C. Check the client’s pain level and provide comfort.
• D. Assess the client’s nutritional status and appetite.

Correct answer: A

Rationale: Correct Answer: Monitoring respiratory status and oxygenation is crucial in clients with lung cancer, as metastasis to the lungs or pleural effusion can compromise breathing. This assessment helps in early identification of respiratory distress and the need for interventions to maintain adequate oxygenation. Choice B is important but not the priority in this situation. Evaluating mental status and cognition should follow after ensuring the client's physiological needs are met. Choice C, checking pain level and providing comfort, is essential but secondary to assessing respiratory status. Choice D, assessing nutritional status and appetite, is also important but not the priority when the client's breathing is at risk.

4. What might be suggested to a client with fibrocystic breasts in an attempt to help relieve symptoms?

• A. Increase intake of high-calcium foods in your diet
• B. Wear a supportive bra during the day and at night
• C. Take over-the-counter pain relievers
• D. Perform regular breast massage

Correct answer: B

Rationale: The correct answer is B: 'Wear a supportive bra during the day and at night.' Wearing a supportive bra is essential for individuals with fibrocystic breasts as it helps relieve discomfort by providing necessary support to reduce strain on breast tissue. Option A is incorrect as high-calcium foods are not directly related to symptom relief in fibrocystic breasts. Option C is not the first-line recommendation and may not address the underlying issue. Option D, performing regular breast massage, is not typically recommended and may not provide significant relief for fibrocystic breast symptoms.

5. A client recently started on warfarin therapy. What laboratory value is most important to monitor for this client?

• A. Platelet count
• B. Prothrombin time (PT)
• C. Creatinine level
• D. Blood urea nitrogen (BUN)

Correct answer: B

Rationale: Prothrombin time (PT) is the most important laboratory value to monitor for clients on warfarin therapy. PT helps determine how long it takes blood to clot and ensures the warfarin dose is within the therapeutic range to prevent either excessive bleeding or clotting. Monitoring platelet count is important for assessing the risk of bleeding, but PT is more specific to warfarin therapy. Creatinine level and BUN are indicators of kidney function and are not directly related to warfarin therapy.

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