Nursing Elites

1. A client had a pituitary tumor removed. Which of the following findings requires further assessment?

• A. Glasgow scale score of 15
• B. Blood drainage on dressing measuring 3 cm
• C. Report of dry mouth
• D. Urinary output greater than fluid intake

Correct answer: D

Rationale: The correct answer is D. Increased urinary output greater than fluid intake can indicate diabetes insipidus, a common complication after pituitary surgery. Diabetes insipidus is characterized by the excretion of a large volume of dilute urine, leading to dehydration and electrolyte imbalances. This finding requires immediate assessment and intervention. Choice A, a Glasgow scale score of 15, indicates normal neurological functioning. Choice B, blood drainage on dressing measuring 3 cm, may require monitoring but is not a priority over the potential complication of diabetes insipidus. Choice C, a report of dry mouth, is a common complaint postoperatively and can be managed with oral care measures.

2. A client with cholecystitis has been prescribed a low-fat diet. Which of the following meal selections by the client indicates understanding of the education?

• A. Roast beef with gravy, mashed potatoes, ice cream
• B. Macaroni and cheese, salad, pudding
• C. Creamed chicken on a roll with peas
• D. Roast turkey, rice pilaf, green beans

Correct answer: D

Rationale: The correct answer is D. Roast turkey is a lean protein option suitable for a low-fat diet. Rice pilaf and green beans are also low in fat. Choices A, B, and C contain high-fat ingredients like gravy, cheese, cream, and ice cream, which are not suitable for a low-fat diet.

3. A client is receiving oxytocin to augment labor. The contractions are occurring every 45 seconds, and the fetal heart rate is 170-180 beats/min. What action should the nurse take?

• A. Increase the oxytocin infusion
• B. Decrease the oxytocin infusion
• C. Discontinue the oxytocin infusion
• D. Maintain the oxytocin infusion

Correct answer: C

Rationale: When contractions occur every 45 seconds with a high fetal heart rate, it indicates uterine hyperstimulation and fetal distress. In this situation, the oxytocin infusion should be discontinued immediately to prevent further complications. Increasing or maintaining the infusion would worsen the hyperstimulation and distress. Decreasing the infusion may not be sufficient to address the current situation and could still lead to complications.

4. A nurse is caring for a client with a new prescription for atorvastatin. Which of the following should the nurse monitor?

• A. Liver function tests
• B. Potassium levels
• C. Blood glucose levels
• D. Serum calcium levels

Correct answer: A

Rationale: The correct answer is A: Liver function tests. Atorvastatin, a medication commonly used to lower cholesterol levels, can potentially cause liver damage as a side effect. Monitoring liver function tests is essential to detect any abnormalities early. Choices B, C, and D are incorrect because atorvastatin is not known to directly impact potassium levels, blood glucose levels, or serum calcium levels. While these parameters may be monitored for other reasons, the priority when administering atorvastatin is to monitor liver function due to the risk of hepatotoxicity.

5. A nurse is monitoring a client who has been receiving intermittent enteral feedings. What should the nurse identify as an intolerance to the feeding?

• A. Increased appetite
• B. Nausea
• C. Weight gain
• D. Regular bowel movements

Correct answer: B

Rationale: Nausea is a common sign of intolerance to enteral feedings. When a client experiences nausea, it can indicate difficulty in tolerating the feeding formula. This intolerance may also manifest as vomiting and dumping syndrome. Choices A, C, and D are incorrect because increased appetite, weight gain, and regular bowel movements are not typical signs of intolerance to enteral feedings.

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