Nursing Elites

1. After receiving a report on an inpatient acute care unit, which client should the nurse assess first?

• A. The client with bowel obstruction due to a volvulus who is experiencing abdominal rigidity
• B. The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds
• C. The client with an obstruction of the large intestine who is experiencing abdominal distention
• D. The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid

Correct answer: A

Rationale: The correct answer is A. Abdominal rigidity in a client with bowel obstruction due to a volvulus indicates possible complications and requires immediate assessment. Choice B is incorrect because although a paralytic ileus with absent bowel sounds is concerning, abdominal rigidity in a client with a volvulus takes priority. Choice C is incorrect as abdominal distention, though indicative of an obstruction, is not as urgent as the sign of abdominal rigidity. Choice D is incorrect as the drainage of greenish fluid from a nasogastric tube in a client with a small bowel obstruction, while concerning, does not present as immediate a threat as the abdominal rigidity in a client with a volvulus.

2. When caring for a laboring client whose contractions are occurring every 2-3 minutes, the nurse should document that the pump is infusing how many ml/hour? (Enter numeric value only. If rounding is required, round to the nearest whole number. Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client’s medical record.)

• A. 5
• B. 10
• C. 15
• D. 20

Correct answer: A

Rationale: The correct infusion rate can be calculated based on the information provided in the chart. With contractions occurring every 2-3 minutes, the recommended infusion rate is 5 ml/hr. This rate ensures proper hydration and medication delivery to support the client during labor. Choices B, C, and D are incorrect as they do not align with the calculated rate based on the contractions frequency and the client's needs.

3. An older adult male is admitted with complications related to chronic obstructive pulmonary disease (COPD). He reports progressive dyspnea that worsens on exertion, and his weakness has increased over the past month. The nurse notes that he has dependent edema in both lower legs. Based on these assessment findings, which dietary instruction should the nurse provide?

• A. Restrict daily fluid intake
• B. Eat meals at the same time daily
• C. Maintain a low-protein diet
• D. Limit the intake of high-calorie foods

Correct answer: A

Rationale: Dependent edema in both lower legs is a sign of fluid overload, which can exacerbate dyspnea in patients with COPD. Restricting daily fluid intake can help reduce the edema and alleviate breathing difficulties. A low-protein diet is not necessary unless there are specific renal concerns. Eating meals at the same time daily or limiting high-calorie foods is not directly associated with addressing fluid overload and dyspnea in COPD patients.

4. A client complains of paresthesia in the fingers and toes and experiences hand spasms when the blood pressure cuff is inflated. Which serum laboratory finding should the nurse expect to find when assessing the client?

• A. Elevated serum calcium
• B. Low serum magnesium
• C. Low serum calcium
• D. Elevated serum potassium

Correct answer: C

Rationale: The correct answer is C: Low serum calcium. Hand spasms and paresthesia are indicative of potential hypocalcemia, which is characterized by low serum calcium levels. Elevated serum calcium (Choice A) is not consistent with the symptoms described. Low serum magnesium (Choice B) and elevated serum potassium (Choice D) are not typically associated with hand spasms and paresthesia.

5. Which intervention should the nurse include in the plan of care for a patient with tetanus?

• A. Open window shades to provide natural light
• B. Encourage coughing and deep breathing
• C. Minimize the amount of stimuli in the room
• D. Reposition from side to side every hour

Correct answer: C

Rationale: The correct intervention for a patient with tetanus is to minimize the amount of stimuli in the room. Tetanus can lead to muscle spasms and heightened sensitivity to stimuli, making it essential to reduce environmental triggers for the patient's comfort and safety. Opening window shades for natural light (Choice A) may exacerbate sensitivity to light and worsen symptoms. Encouraging coughing and deep breathing (Choice B) is not directly related to managing tetanus symptoms. While repositioning the patient every hour (Choice D) is important for preventing pressure ulcers, it is not the priority when managing tetanus, which requires a quiet, low-stimulus environment to minimize muscle spasms and discomfort.

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