Nursing Elites

1. A nurse is assessing a client who has acute pancreatitis. Which of the following findings should the nurse expect?

• A. Left upper quadrant pain.
• B. Periumbilical pain.
• C. Rebound tenderness.
• D. Flank pain.

Correct answer: A

Rationale: Corrected Rationale: The correct answer is A, left upper quadrant pain. In acute pancreatitis, inflammation of the pancreas commonly causes pain in the left upper quadrant of the abdomen. This pain can be severe and radiate to the back. Periumbilical pain (choice B) is more indicative of acute appendicitis. Rebound tenderness (choice C) is associated with peritoneal inflammation, not specifically pancreatitis. Flank pain (choice D) is more characteristic of conditions involving the kidneys or ureters, such as renal colic.

2. A client receiving radiation therapy for breast cancer may experience which of the following side effects that the nurse should monitor for?

• A. Fatigue
• B. Nausea
• C. Skin irritation
• D. Weight gain

Correct answer: C

Rationale: During radiation therapy for breast cancer, one common side effect is skin irritation due to the impact of radiation on the skin cells. This side effect should be closely monitored by the nurse. Fatigue may also occur as a side effect of radiation therapy, but skin irritation is more specific to the treatment area and is a priority in this case. Nausea and weight gain are not typically associated with radiation therapy for breast cancer, making them incorrect choices.

3. A client who is at 38 weeks gestation, is in active labor, and has ruptured membranes. Which of the following actions should the nurse take?

• A. Insert an indwelling urinary catheter
• B. Apply fetal heart rate monitor
• C. Initiate fundal massage
• D. Initiate an oxytocin IV infusion

Correct answer: B

Rationale: Applying a fetal heart rate monitor is the priority action in this scenario as it helps assess the well-being of the fetus during labor. This monitoring is crucial to detect any signs of fetal distress and guide interventions. Inserting an indwelling urinary catheter (Choice A) is not a priority at this time unless there are specific indications. Initiating fundal massage (Choice C) is not necessary in this situation as the focus should be on fetal assessment. Initiating an oxytocin IV infusion (Choice D) is not indicated until the stage of labor and the progress of labor are determined.

4. Which electrolyte imbalance is most common in patients receiving furosemide?

• A. Hypokalemia
• B. Hypercalcemia
• C. Hyponatremia
• D. Hyperkalemia

Correct answer: A

Rationale: The correct answer is A, Hypokalemia. Furosemide, a loop diuretic, commonly leads to potassium loss in the urine, causing hypokalemia. This electrolyte imbalance should be closely monitored in patients taking furosemide. Choices B, C, and D are incorrect because hypercalcemia, hyponatremia, and hyperkalemia are not typically associated with furosemide use.

5. A healthcare professional is assessing a client who has a new prescription for digoxin. Which of the following findings is the priority for the healthcare professional to report to the provider?

• A. Heart rate of 58/min
• B. Weight gain of 1 kg (2.2 lb) in 24 hours
• C. Respiratory rate of 20/min
• D. Temperature of 37.3°C (99.1°F)

Correct answer: A

Rationale: The correct answer is A. A heart rate of 58/min is indicative of bradycardia, a potential sign of digoxin toxicity, which should be reported immediately. While weight gain, respiratory rate, and temperature are important parameters to monitor, they are not as critical as identifying bradycardia in a client taking digoxin.

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