Nursing Elites

1. A patient with cirrhosis of the liver and ascites is scheduled for a paracentesis. What should the nurse do to prepare the patient for the procedure?

• A. Have the patient void immediately before the procedure.
• B. Position the patient upright or semi-Fowler's in bed.
• C. Administer a full liquid diet.
• D. Encourage the patient to ambulate for 30 minutes.

Correct answer: A

Rationale: The correct preparation for a paracentesis in a patient with cirrhosis and ascites includes having the patient void immediately before the procedure. This is important to reduce the risk of bladder puncture during the paracentesis. Positioning for a paracentesis is typically upright or semi-Fowler's, not flat in bed. Administering a full liquid diet or encouraging ambulation for 30 minutes are not directly related to preparing a patient for a paracentesis procedure.

2. Following a CVA, the nurse assesses that a client has developed dysphagia, hypoactive bowel sounds, and a firm, distended abdomen. Which prescription for the client should the nurse question?

• A. Continuous tube feeding at 65 ml/hr via gastrostomy.
• B. Total parenteral nutrition to be infused at 125 ml/hour.
• C. Nasogastric tube connected to low intermittent suction.
• D. Metoclopramide (Reglan) intermittent piggyback.

Correct answer: A

Rationale: In a client with dysphagia and gastrointestinal symptoms such as hypoactive bowel sounds and a firm, distended abdomen, continuous tube feeding might exacerbate the symptoms. This can lead to complications and should be questioned by the nurse.

3. A male client is admitted to the neurological unit. He has just sustained a C-5 spinal cord injury. Which assessment finding of this client warrants immediate intervention by the nurse?

• A. Is unable to feel sensation in the arms and hands.
• B. Has flaccid upper and lower extremities.
• C. Blood pressure is 110/70 and the apical pulse is 68.
• D. Respirations are shallow, labored, and 14 breaths/minute.

Correct answer: D

Rationale: Respirations that are shallow, labored, and at 14 breaths/minute indicate potential respiratory compromise, which is a critical situation requiring immediate intervention to maintain adequate oxygenation and prevent respiratory failure.

4. The healthcare provider in the outpatient clinic has obtained health histories for these new patients. Which patient may need referral for genetic testing?

• A. 35-year-old patient whose maternal grandparents died after strokes at ages 90 and 96
• B. 18-year-old patient with a positive pregnancy test whose first child has cerebral palsy
• C. 34-year-old patient who has a sibling with newly diagnosed polycystic kidney disease
• D. 50-year-old patient with a history of cigarette smoking who is complaining of dyspnea

Correct answer: C

Rationale: The 34-year-old patient who has a sibling with newly diagnosed polycystic kidney disease may need referral for genetic testing. Polycystic kidney disease is an autosomal dominant disorder that can be asymptomatic until later in life. Presymptomatic testing can provide valuable information for guiding lifestyle and family planning decisions. The other patients do not present indications for genetic testing based on the information provided in their health histories. The 35-year-old patient's maternal grandparents' strokes are not indicative of a need for genetic testing. The 18-year-old patient's child having cerebral palsy is not a direct indication for genetic testing of the patient herself. The 50-year-old patient's symptoms are more likely related to smoking and respiratory issues, not genetic predisposition to a specific disease.

5. The healthcare provider formulates a nursing diagnosis of 'High risk for ineffective airway clearance' for a client with myasthenia gravis. What is the most likely cause for this nursing diagnosis?

• A. Pain during coughing.
• B. Diminished cough effort.
• C. Thick, dry secretions.
• D. Excessive inflammation.

Correct answer: B

Rationale: Clients with myasthenia gravis commonly experience muscle weakness, including in the muscles used for coughing. This diminished cough effort can lead to ineffective airway clearance, increasing the risk of respiratory complications. Therefore, the most likely cause for the nursing diagnosis 'High risk for ineffective airway clearance' in a client with myasthenia gravis is the diminished cough effort due to muscle weakness.

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