Nursing Elites

1. Because the census is currently low in the Obstetrics (OB) unit, one of the nurses is sent to work on a medical-surgical unit for the day, or until the OB unit becomes busy. Which client assessment is best for the charge nurse to assign to the OB nurse?

• A. An adult who had a colon resection yesterday and has an IV.
• B. An older adult who has a fever of unknown origin.
• C. A woman who had an acute brain attack (stroke, CVA) 6 hours ago.
• D. A teenager with a femoral fracture who is in traction.

Correct answer: A

Rationale: The OB nurse is most experienced in postoperative care, making the client who had a recent colon resection the most suitable assignment. This client would require care that aligns closely with the expertise and skills of the OB nurse, ensuring optimal patient outcomes and effective utilization of nursing resources.

2. Which intervention should the nurse implement to enhance the efficacy of the client's asthma medication therapy?

• A. Administer the albuterol inhaler before other inhaled medications.
• B. Provide oxygen via nasal cannula at 2 liters/minute.
• C. Encourage the client to drink three liters of fluids daily.
• D. Keep the client upright during nebulizer therapy.

Correct answer: A

Rationale: Administering a bronchodilator such as albuterol as the first step is crucial to open the airways, allowing better penetration of subsequent inhaled medications and enhancing their overall efficacy in managing asthma symptoms.

3. A client has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The client's current medication regimen includes lactulose four times daily. What desired outcome should the nurse relate to this pharmacologic intervention?

• A. Two to three soft bowel movements daily
• B. Significant increase in appetite and food intake
• C. Absence of nausea and vomiting
• D. Absence of blood or mucus in stool

Correct answer: A

Rationale: Lactulose is used in hepatic encephalopathy to reduce blood ammonia levels by promoting bowel movements. The desired outcome of lactulose therapy is typically two to three soft bowel movements daily, which helps in eliminating excess ammonia from the body, thus improving the client's condition.

4. A client with a cold is taking the antitussive benzonatate (Tessalon). Which assessment data indicates to the nurse that the medication is effective?

• A. Reports reduced nasal discharge.
• B. Denies having coughing spells.
• C. Able to sleep through the night.
• D. Expectorating bronchial secretions.

Correct answer: B

Rationale: The correct answer is B. Denying having coughing spells indicates the effectiveness of benzonatate, an antitussive that suppresses coughing. The goal of antitussive medications like benzonatate is to reduce or eliminate coughing, so the absence of coughing spells signifies the drug's efficacy. The other options do not directly reflect the medication's intended effect and are not specific indicators of benzonatate's effectiveness.

5. Why is a low-protein diet recommended for a client with hepatic encephalopathy?

• A. Hyperglycemia
• B. Hypoglycemia
• C. Increased ammonia levels
• D. Electrolyte imbalance

Correct answer: C

Rationale: A low-protein diet is recommended for clients with hepatic encephalopathy to reduce ammonia levels. Ammonia, a byproduct of protein metabolism, can accumulate in the blood due to impaired liver function. Elevated ammonia levels can lead to worsening hepatic encephalopathy, a condition characterized by cognitive and neurological disturbances. Therefore, by limiting protein intake, the production of ammonia is reduced, thereby helping to manage hepatic encephalopathy. Choices A, B, and D are incorrect because hepatic encephalopathy is not primarily related to hyperglycemia, hypoglycemia, or electrolyte imbalance. The focus is on reducing ammonia levels to improve the condition.

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