Nursing Elites

1. After receiving lactulose, a client with hepatic encephalopathy has several loose stools. What action should the nurse implement?

• A. Send stool specimen to the lab
• B. Measure abdominal girth
• C. Encourage increased fiber in the diet
• D. Monitor mental status

Correct answer: D

Rationale: The correct action for the nurse to implement after a client with hepatic encephalopathy has loose stools following lactulose administration is to monitor the client's mental status. Lactulose is given to lower serum ammonia levels in hepatic encephalopathy, and loose stools can be an expected side effect of its use. Monitoring mental status is crucial because changes in mental status, such as confusion or altered level of consciousness, are key indicators of hepatic encephalopathy worsening. Sending a stool specimen to the lab would not be the priority in this situation as loose stools are a known effect of lactulose. Measuring abdominal girth is more relevant for conditions like ascites, not loose stools. Encouraging increased fiber in the diet may be beneficial for constipation but is not the immediate action needed when loose stools occur after lactulose administration.

2. An adult female client with chronic kidney disease (CKD) asks the nurse if she can continue taking over-the-counter medications. Which medication provides the greatest threat to this client?

• A. Magnesium hydroxide (Maalox).
• B. Birth control pills.
• C. Cough syrup containing codeine.
• D. Cold medication containing alcohol.

Correct answer: A

Rationale: The correct answer is A: Magnesium hydroxide (Maalox). In clients with CKD, magnesium can accumulate to toxic levels due to decreased excretion by the kidneys. Therefore, it poses the greatest threat to this client population. Choice B, birth control pills, is not typically contraindicated in CKD. Choice C, cough syrup containing codeine, may require dose adjustments but is not the greatest threat. Choice D, cold medication containing alcohol, is a concern mainly in liver disease, not CKD.

3. A nurse is caring for a client with Diabetes Insipidus. Which assessment finding warrants immediate intervention by the nurse?

• A. Hypernatremia
• B. Excessive thirst
• C. Elevated heart rate
• D. Poor skin turgor

Correct answer: A

Rationale: The correct answer is A: Hypernatremia. In a client with Diabetes Insipidus, hypernatremia, an elevated sodium level in the blood, can lead to neurological symptoms such as confusion, seizures, or coma. Immediate intervention is necessary to prevent these serious complications. Excessive thirst (choice B) is a common symptom of Diabetes Insipidus but does not require immediate intervention. Elevated heart rate (choice C) and poor skin turgor (choice D) are important assessments but are not as critical as hypernatremia in this context.

4. Which nursing intervention is most important when caring for a client with myasthenia gravis?

• A. Encourage the client to rest frequently.
• B. Administer medication 30 minutes before meals.
• C. Maintain a patent airway.
• D. Monitor for signs of respiratory infection.

Correct answer: C

Rationale: Maintaining a patent airway is crucial for clients with myasthenia gravis because muscle weakness can affect the muscles responsible for breathing, potentially leading to respiratory compromise. Encouraging rest, administering medication, and monitoring for respiratory infections are important aspects of care but do not take precedence over ensuring a patent airway for adequate oxygenation.

5. The nurse is assessing a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which assessment finding is most concerning?

• A. Increased fatigue
• B. Elevated blood pressure
• C. Low urine output
• D. Elevated hemoglobin

Correct answer: B

Rationale: In a client with chronic kidney disease (CKD) receiving erythropoietin therapy, an elevated blood pressure is the most concerning assessment finding. Elevated blood pressure can indicate worsening hypertension, which requires immediate intervention. Increased fatigue may be expected due to anemia associated with CKD and erythropoietin therapy. Low urine output may indicate impaired kidney function but is not as immediately concerning as elevated blood pressure. Elevated hemoglobin levels are the desired outcome of erythropoietin therapy, indicating an appropriate response to treatment.

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