Nursing Elites

1. A patient comes to the clinic complaining of frequent, watery stools for the last 2 days. Which action should the nurse take first?

• A. Obtain the baseline weight
• B. Check the patient’s blood pressure
• C. Draw blood for serum electrolyte levels
• D. Ask about any extremity numbness or tingling

Correct answer: B

Rationale: The correct answer is to check the patient’s blood pressure. Given the patient's symptoms of frequent, watery stools, there is a concern for fluid volume deficit. Assessing the blood pressure helps determine the patient's perfusion status, which is crucial in managing fluid volume deficits. While obtaining baseline weight, drawing blood for serum electrolyte levels, and asking about extremity numbness or tingling are important assessments, checking the blood pressure takes precedence as it provides immediate information on the patient's circulatory status.

2. A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results?

• A. Metabolic acidosis
• B. Metabolic alkalosis
• C. Respiratory acidosis
• D. Respiratory alkalosis

Correct answer: A

Rationale: The patient's pH is below the normal range (7.35-7.45), and the HCO3 is also below the normal range (22-26 mEq/L), indicating an acidic environment, which is consistent with metabolic acidosis. The ABGs provided do not support respiratory acidosis or alkalosis, as the PaCO2 is within the normal range (35-45 mm Hg) despite the patient's deep, rapid respirations. Therefore, the correct interpretation is metabolic acidosis.

3. A 54-year-old male client and his wife were informed this morning that he has terminal cancer. Which nursing intervention is likely to be most beneficial?

• A. Ask the wife how she would like to participate in the client's care
• B. Provide the wife with information about hospice
• C. Encourage the wife to visit after painful treatments are completed
• D. Refer the wife to a support group for family members of those dying of cancer

Correct answer: A

Rationale: The most beneficial nursing intervention in this situation is to ask the wife how she would like to participate in the client's care. Involving the spouse in the care of the terminally ill client can provide comfort, support, and a sense of contribution during a challenging time. Providing information about hospice (B) is important but may not be the immediate priority. Encouraging the wife to visit after treatments are completed (C) may delay her involvement in the care. Referring her to a support group (D) is a good idea but might be more suitable at a later stage.

4. The nurse requests a meal tray for a client who follows Mormon beliefs and who is on a clear liquid diet following abdominal surgery. Which menu items should the nurse request for this client? (Select all that apply)

• A. apple juice
• B. black coffee
• C. orange juice
• D. hot chocolate

Correct answer: A

Rationale: The correct answer is A: apple juice. Clear liquids like apple juice and orange juice are suitable for a client following a clear liquid diet and Mormon beliefs. Options B and D, black coffee and hot chocolate, contain caffeine, which may not align with the client's religious dietary restrictions. Therefore, these options should be avoided for this client.

5. A client with bladder cancer had surgical placement of a ureteroileostomy (ileal conduit) yesterday. Which postoperative assessment finding should the nurse report to the healthcare provider immediately?

• A. red and edematous stoma appearance
• B. liquid brown drainage from stoma
• C. stoma output of 40ml in the last hour
• D. mucous strings floating in the drainage

Correct answer: C

Rationale: Stoma output of only 40ml in the last hour may indicate a problem, such as dehydration or blockage, and should be reported immediately. A red and edematous stoma appearance could be due to inflammation, which is expected in the early postoperative period. Liquid brown drainage from the stoma is a normal finding. Mucous strings floating in the drainage are also a common occurrence postoperatively and do not typically require immediate reporting.

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