Nursing Elites

1. A female client reports that she drank a liter of a solution to cleanse her intestines but vomited immediately. How many ml of fluid intake should the nurse document?

• A. 240 ml
• B. 500 ml
• C. 760 ml
• D. 1000 ml

Correct answer: C

Rationale: The correct answer is 760 ml. After vomiting 240 ml (1 cup), the nurse should document the remaining 760 ml as the fluid intake. Choice A (240 ml) is the amount vomited, not the total intake. Choice B (500 ml) and Choice D (1000 ml) are the total intake, not considering the vomiting.

2. An 80-year-old male client with multiple chronic health problems becomes disoriented, agitated, and combative 24 hours after being admitted to the hospital. What nursing intervention is most important to include in this client's plan of care?

• A. Request a psychiatric consultation for the client.
• B. Reorient the client frequently to time, place, and person.
• C. Administer prescribed antipsychotic medications to reduce agitation.
• D. Obtain an order for a sitter to stay with the client.

Correct answer: B

Rationale: Reorienting the client frequently is the most important nursing intervention in this scenario. It helps reduce confusion and agitation, which are common symptoms of acute delirium in hospitalized elderly clients. Requesting a psychiatric consult (choice A) may be necessary if the reorientation does not improve the client's condition or if there are underlying psychiatric concerns, but reorientation should be attempted first. Administering antipsychotic medications (choice C) should not be the initial intervention as they can have adverse effects in elderly individuals. Obtaining a sitter (choice D) may provide support but does not directly address the client's disorientation and agitation.

3. A nurse is teaching a client with type 2 diabetes about the importance of foot care. Which statement by the client indicates a need for further teaching?

• A. I should check my feet every day for cuts or blisters.
• B. I need to moisturize my feet daily, especially between my toes.
• C. I should wear comfortable shoes that fit well.
• D. I should avoid walking barefoot, even indoors.

Correct answer: B

Rationale: The correct answer is B. Moisturizing between the toes can create a moist environment that fosters fungal infections. Checking the feet daily for cuts or blisters (choice A) is correct in diabetes management to prevent complications. Wearing comfortable shoes that fit well (choice C) and avoiding walking barefoot (choice D) are also essential in preventing foot ulcers and injuries in diabetic patients.

4. A gravida 2 para 1, at 38-weeks gestation, scheduled for a repeat cesarean section in one week, is brought to the labor and delivery unit complaining of contractions every 10 minutes. While assessing the client, the client's mother enters the labor suite and says in a loud voice, 'I've had 8 children and I know she's in labor. I want her to have her cesarean section right now!' What action should the nurse take?

• A. Tell the mother to stop speaking for the client.
• B. Notify the charge nurse of the situation.
• C. Request that the mother leave the room.
• D. Request security to remove her from the room.

Correct answer: C

Rationale: In this scenario, the most appropriate action for the nurse to take is to request that the mother leave the room. This is important to maintain a calm environment and allow the healthcare team to assess and manage the situation without interference. Option A is not the best choice as it may escalate the situation. Option B, notifying the charge nurse, could be considered after addressing the immediate need to remove the mother from the room. Option D, requesting security to remove her, is not necessary at this point and may further escalate the situation unnecessarily.

5. Following a lumbar puncture, a client voices several complaints. What complaint indicates to the nurse that the client is experiencing a complication?

• A. I am having pain in my lower back when I move my legs
• B. My throat hurts when I swallow
• C. I feel sick to my stomach and am going to throw up
• D. I have a headache that gets worse when I sit up

Correct answer: D

Rationale: The correct answer is D. A post-lumbar puncture headache, ranging from mild to severe, may occur as a result of leakage of cerebrospinal fluid at the puncture site. This complication is usually managed by bed rest, analgesics, and hydration. Choices A, B, and C do not directly indicate complications associated with a lumbar puncture. Pain in the lower back when moving legs, a sore throat when swallowing, and nausea with a feeling of vomiting are not typical complications of lumbar puncture.

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