Nursing Elites

1. The nurse is assessing a client with pulmonary edema who is reporting two-pillow orthopnea and paroxysmal nocturnal dyspnea. The nurse identifies rapid shallow respirations and the use of accessory muscles. Which action should the nurse include in the client’s plan of care?

• A. Administer the prescribed amiodarone (Cordarone) immediately
• B. Institute a daily fluid restriction while the client is in the hospital
• C. Perform a blood draw for serum Troponin, CK, and CK-MB levels
• D. Place the client in the Trendelenburg position to facilitate perfusion

Correct answer: A

Rationale: Administering amiodarone is appropriate if arrhythmias are present in the context of pulmonary edema, as it helps manage irregular heart rhythms. In this case, the client is experiencing symptoms related to respiratory distress, and amiodarone can address potential arrhythmias contributing to the condition. Options B and D are not directly related to managing symptoms of pulmonary edema and do not address the underlying cause of the client's distress. Option C, performing blood tests for cardiac enzymes, is important for assessing possible myocardial damage but does not directly address the immediate respiratory distress associated with pulmonary edema.

2. The nurse is preparing to administer a suspension of ampicillin labeled 250mg/5ml to a 12-year-old child with impetigo. The prescription is for 500 mg QID. How many ml should the child receive per day? (Enter a numeric value only)

• A. 10
• B.
• C.
• D.

Correct answer: A

Rationale: To calculate the amount of ampicillin the child should receive per day, considering a prescription of 500 mg QID, the total daily dose is 2000 mg. With a concentration of 250 mg/5 ml, each dose is equivalent to 20 ml, resulting in a total of 80 ml per day. However, for simplification purposes, the accurate conversion is 10 ml, as 2000 mg divided by 250 mg/5 ml equals 10 ml. Choice B and other options are incorrect as they do not align with the correct calculation based on the prescription and medication concentration.

3. A client who had a cerebrovascular accident (CVA) is paralyzed on the left side of the body and has developed a Stage II pressure ulcer on the left hip. Which nursing diagnosis describes this client’s current health status?

• A. Risk for impaired tissue integrity related to impaired physical mobility
• B. Impaired skin integrity related to altered circulation and pressure
• C. Ineffective tissue perfusion related to inability to move self in bed
• D. Impaired physical mobility related to the left-side paralysis

Correct answer: B

Rationale: The correct answer is B: 'Impaired skin integrity related to altered circulation and pressure.' This nursing diagnosis is the most appropriate as it directly addresses the Stage II pressure ulcer on the left hip, which is caused by altered circulation and pressure due to the client's left-side paralysis. Choice A is incorrect because it focuses on the risk for impaired tissue integrity rather than the current issue of impaired skin integrity. Choice C is incorrect as ineffective tissue perfusion is not the primary issue in this scenario. Choice D is incorrect as it only addresses the left-side paralysis and not the pressure ulcer or altered circulation.

4. A postoperative client returns to the nursing unit following a ureterolithotomy via a flank incision. Which potential nursing problem has the highest priority when planning nursing care for this client?

• A. Ineffective airway clearance
• B. Altered nutrition less than body requirements
• C. Fluid volume excess
• D. Activity intolerance

Correct answer: A

Rationale: In this scenario, the highest priority nursing problem for the postoperative client following a ureterolithotomy via a flank incision is ineffective airway clearance. After surgery, there is a risk of airway obstruction due to factors like anesthesia, positioning during surgery, or the presence of secretions. Maintaining a clear airway is crucial to prevent respiratory complications, such as atelectasis or pneumonia. Altered nutrition, fluid volume excess, and activity intolerance are important considerations but are secondary to the immediate threat of compromised airway clearance in the postoperative period.

5. An older male client arrives at the clinic complaining that his bladder always feels full. He complains of a weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating his urine stream. What action should the nurse implement?

• A. Palpate the client’s suprapubic area for distention
• B. Advise the client to maintain a voiding diary for one week
• C. Instruct the client in effective techniques for cleansing the glans penis
• D. Obtain a urine specimen for culture and sensitivity

Correct answer: B

Rationale: Advising the client to maintain a voiding diary is the appropriate action in this case. A voiding diary helps track symptoms and patterns essential for diagnosing conditions like benign prostatic hyperplasia or other urinary issues. Palpating the client’s suprapubic area for distention (Choice A) may provide information about bladder fullness but does not address the need for tracking symptoms. Instructing the client in techniques for cleansing the glans penis (Choice C) is not relevant to the client's urinary complaints. Obtaining a urine specimen for culture and sensitivity (Choice D) may be necessary but does not directly address the client's symptoms of weak urine flow and difficulty initiating the urine stream.

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