Nursing Elites

1. After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and malnutrition. The client is drowsy but responding to verbal stimuli and reports recently spitting up blood. What assessment finding warrants immediate intervention by the nurse?

• A. Bruises on arms and legs
• B. Round and tight abdomen
• C. Pitting edema in lower legs
• D. Capillary refill of 8 seconds

Correct answer: D

Rationale: In this situation, the client's capillary refill of 8 seconds is the assessment finding that warrants immediate intervention by the nurse. A capillary refill greater than 3 to 5 seconds indicates poor perfusion, which could be a sign of inadequate circulation and oxygenation. Checking capillary refill is a quick and useful way to assess peripheral perfusion. Bruises on arms and legs may indicate a bleeding disorder but are not as urgent as addressing poor perfusion. A round and tight abdomen could suggest ascites, which is already known in this case. Pitting edema in lower legs is a common finding in malnutrition and ascites but does not require immediate intervention as poor capillary refill does.

2. A client with a history of angina pectoris is prescribed sublingual nitroglycerin. Which client statement indicates that further teaching is needed?

• A. ‘I should take the nitroglycerin with a full glass of water.’
• B. ‘I should take the nitroglycerin as soon as I feel chest pain.’
• C. ‘I can take up to three doses of nitroglycerin if needed.’
• D. ‘I should call 911 if my chest pain does not improve after the first dose.’

Correct answer: A

Rationale: The correct answer is A. Sublingual nitroglycerin should not be taken with water, as it needs to dissolve under the tongue to be effective. Option B is correct as the client should take nitroglycerin as soon as they feel chest pain. Option C is correct as up to three doses can be taken if needed. Option D is correct as the client should seek emergency help if chest pain does not improve after the first dose.

3. The unit clerk reports to the charge nurse that a healthcare provider has written several prescriptions that are illegible and it appears the healthcare provider used several unapproved abbreviations in the prescriptions. What actions should the charge nurse take?

• A. Call the healthcare provider who wrote the prescription
• B. Attempt to clarify the prescriptions with the pharmacist
• C. Administer the medications as prescribed
• D. Ask another healthcare provider for clarification

Correct answer: A

Rationale: The correct action for the charge nurse to take is to call the healthcare provider who wrote the illegible prescriptions. It is crucial to clarify illegible prescriptions directly with the provider to ensure patient safety and prevent medication errors. Option B, attempting to clarify with the pharmacist, may lead to misinterpretation and is not the recommended first step. Administering the medications as prescribed without clarity can jeopardize patient safety, making option C incorrect. Asking another healthcare provider for clarification (option D) may not be effective as the responsibility lies with the provider who wrote the prescription.

4. A client with cirrhosis is admitted with jaundice and ascites. Which assessment finding requires immediate intervention?

• A. Peripheral edema
• B. Confusion and altered mental status
• C. Yellowing of the skin
• D. Increased abdominal girth

Correct answer: B

Rationale: Confusion and altered mental status are the most critical assessment findings in a client with cirrhosis. These symptoms may indicate hepatic encephalopathy, a serious complication that requires immediate intervention. Yellowing of the skin (jaundice) is a common manifestation of cirrhosis and does not necessitate immediate intervention. Peripheral edema and increased abdominal girth are associated with fluid retention in cirrhosis but are not as urgent as addressing altered mental status and confusion.

5. The nurse is assessing a primigravida at 39-weeks gestation during a weekly prenatal visit. Which finding is most important for the nurse to report to the healthcare provider?

• A. Fetal heart rate of 200 beats/minute.
• B. Mild ankle edema.
• C. Complaints of back pain.
• D. Decreased fetal movements.

Correct answer: A

Rationale: A fetal heart rate of 200 beats per minute is significantly elevated and requires immediate medical attention. This finding could indicate fetal distress, tachycardia, or other serious issues that need prompt evaluation. Mild ankle edema, complaints of back pain, and decreased fetal movements are common in pregnancy but are not as urgent or concerning as a high fetal heart rate.

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