Nursing Elites

1. A client with heart failure is prescribed furosemide (Lasix). Which instruction should the nurse include in the client's teaching plan?

• A. Take the medication before bedtime.
• B. Report any weight gain of more than 2 pounds in a day.
• C. Increase your intake of high-sodium foods.
• D. Limit your fluid intake to less than 1 liter per day.

Correct answer: B

Rationale: In heart failure, fluid retention is a concern. Furosemide helps manage this by promoting diuresis. Instructing the client to report weight gain exceeding 2 pounds in a day is crucial as it can indicate fluid accumulation, prompting timely intervention to prevent worsening heart failure symptoms and complications.

2. The client has acute pancreatitis. Which nursing intervention is the highest priority?

• A. Administer pain medication as prescribed.
• B. Monitor the client's serum amylase and lipase levels.
• C. Encourage oral intake of clear liquids.
• D. Assess the client's bowel sounds every 4 hours.

Correct answer: A

Rationale: Administering pain medication as prescribed is the highest priority when caring for a client with acute pancreatitis. Acute pancreatitis is often associated with severe abdominal pain, and alleviating this pain is crucial for the client's comfort and well-being. Pain management can also help reduce stress on the pancreas and promote recovery. Monitoring serum amylase and lipase levels, encouraging oral intake of clear liquids, and assessing bowel sounds are important interventions but addressing the client's pain takes precedence to provide immediate relief and improve outcomes.

3. The healthcare provider is caring for a client who has just undergone a thyroidectomy. Which assessment finding requires immediate intervention?

• A. Hoarse voice.
• B. Difficulty swallowing.
• C. Numbness and tingling around the mouth.
• D. Sore throat.

Correct answer: C

Rationale: Numbness and tingling around the mouth can indicate hypocalcemia, a potential complication after thyroidectomy. Hypocalcemia can occur due to inadvertent injury or removal of the parathyroid glands during the thyroidectomy, leading to decreased calcium levels. As a result, the client may experience symptoms such as numbness, tingling, muscle cramps, or spasms. Prompt intervention is necessary to prevent severe complications like tetany or seizures. Therefore, the healthcare provider should address numbness and tingling around the mouth immediately to prevent further deterioration of calcium levels and potential serious outcomes. Choices A, B, and D are not typically associated with immediate post-thyroidectomy complications and can be addressed after ensuring the client's calcium levels are stable.

4. A client with hepatic encephalopathy is being treated with lactulose. What is an expected outcome of this treatment?

• A. Reduction in blood ammonia levels
• B. Improvement in liver enzyme levels
• C. Decrease in bilirubin levels
• D. Increase in urine output

Correct answer: A

Rationale: Lactulose is used to treat hepatic encephalopathy by reducing blood ammonia levels through promoting its excretion via the intestines. Elevated ammonia levels contribute to the development of encephalopathy symptoms, so by lowering them, the client's neurological status can improve.

5. A 50-year-old man presents with progressive jaundice, dark urine, and pruritus. Imaging reveals a mass in the head of the pancreas. What is the most likely diagnosis?

• A. Pancreatic cancer
• B. Chronic pancreatitis
• C. Gallstones
• D. Primary sclerosing cholangitis

Correct answer: A

Rationale: The presentation of progressive jaundice, dark urine, and pruritus along with a pancreatic mass, particularly in the head of the pancreas, strongly suggests pancreatic cancer as the most likely diagnosis. These symptoms are classic for obstructive jaundice caused by a mass in the head of the pancreas, making pancreatic cancer the most fitting choice.

Similar Questions