Nursing Elites

1. A young adult female presents at the emergency center with acute lower abdominal pain. Which assessment finding is most important for the nurse to report to the healthcare provider?

• A. Pain scale rating of 9 on a 0-10 scale
• B. Last menstrual period was 7 weeks ago
• C. Reports white curdy vaginal discharge
• D. History of irritable bowel syndrome (IBS)

Correct answer: B

Rationale: The correct answer is B. A missed menstrual period could indicate a possible pregnancy-related issue, requiring urgent evaluation. Assessing the menstrual history in a female of reproductive age takes precedence in this scenario. Choice A, the pain scale rating, is important but not as urgent as evaluating the menstrual history. Choice C, reporting white curdy vaginal discharge, may suggest a vaginal infection but is not as critical as ruling out a potential pregnancy. Choice D, the history of irritable bowel syndrome, is relevant but not as crucial as determining pregnancy-related issues in this context.

2. A client with intestinal obstructions has a nasogastric tube to low intermittent suction and is receiving an IV of lactated Ringer’s at 100 ml/H. Which finding is most important for the nurse to report to the healthcare provider?

• A. Gastric output of 900 mL in the last 24 hours
• B. Serum potassium level of 3.1 mEq/L or mmol/L (SI)
• C. Increased blood urea nitrogen (BUN)
• D. 24-hour intake at the current infusion rate

Correct answer: B

Rationale: The most crucial finding to report to the healthcare provider in this scenario is a serum potassium level of 3.1 mEq/L. Hypokalemia can lead to serious complications, including cardiac issues. Gastric output, increased BUN, and monitoring the 24-hour intake are essential but do not pose an immediate risk as hypokalemia does in this situation.

3. Several clients on a telemetry unit are scheduled for discharge in the morning, but a telemetry-monitored bed is needed immediately. The charge nurse should make arrangements to transfer which client to another medical unit? The client who is

• A. Learning to self-administer insulin injections after being diagnosed with diabetes mellitus
• B. Ambulatory following coronary artery bypass graft surgery performed six days ago.
• C. Wearing a sling immobilizer following permanent pacemaker insertion earlier that day
• D. Experiencing syncopal episodes resulting from dehydration caused by severe diarrhea

Correct answer: B

Rationale: The correct answer is B because the client who is ambulatory following coronary artery bypass graft surgery performed six days ago is stable enough for transfer compared to the other clients. Choice A should not be transferred as the client is still in the learning phase of self-administering insulin injections after being diagnosed with diabetes mellitus, requiring close monitoring. Choice C should not be transferred immediately after having a permanent pacemaker insertion as they need telemetry monitoring for any complications. Choice D should not be transferred as the client is experiencing syncopal episodes due to dehydration caused by severe diarrhea, requiring immediate intervention and close monitoring on the telemetry unit.

4. A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care, the nurse finds the radiation implant in the bed. What action should the nurse take?

• A. Call the radiology department
• B. Reinsert the implant into the vagina
• C. Apply double gloves to retrieve the implant for disposal
• D. Place the implant in a lead container using long-handled forceps

Correct answer: D

Rationale: The correct action for the nurse to take when finding a radiation implant in the bed is to place the implant in a lead container using long-handled forceps. This action is crucial to minimize radiation exposure to both the patient and healthcare providers and ensure the safe disposal of the radioactive material. Calling the radiology department (choice A) may lead to unnecessary delays in addressing the immediate safety concern. Reinserting the implant into the vagina (choice B) is contraindicated and can cause harm. Applying double gloves to retrieve the implant for disposal (choice C) is not adequate for ensuring proper containment and handling of the radioactive implant, which requires specialized equipment like a lead container and long-handled forceps.

5. When lactulose (Cephulac) 30 ml QID is prescribed for a male client with advanced cirrhosis, and he complains that it causes diarrhea, what action should the nurse take in response to the client’s statement?

• A. Explain that diarrhea is expected, but the drug reduces ammonia levels
• B. Document that the client is non-compliant with his treatment plan
• C. Tell the client to be concerned about more significant side effects of this drug
• D. Obtain a prescription for loperamide (Imodium) 4mg PO PRN diarrhea

Correct answer: A

Rationale: The correct answer is A. Diarrhea is an expected side effect of lactulose when used to reduce ammonia levels in cirrhosis. It helps in decreasing the absorption of ammonia in the colon, thereby reducing its levels in the blood. Option B is incorrect because it is essential for the nurse to educate the client about the expected side effects of the medication rather than assuming non-compliance. Option C is incorrect as it instills unnecessary fear in the client by suggesting more significant side effects without addressing the current concern. Option D is incorrect as loperamide should not be given automatically for diarrhea caused by lactulose, as the diarrhea is a therapeutic effect of the medication in this context.

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