Nursing Elites

1. The nurse is palpating the right upper hypochondriac region of the abdomen of a client. What organ lies underneath this area?

• A. Duodenum
• B. Gastric pylorus
• C. Liver
• D. Spleen

Correct answer: C

Rationale: The correct answer is C: Liver. The liver is located in the right upper hypochondriac region of the abdomen. The duodenum (Choice A) is located in the right upper quadrant but not directly underneath the right upper hypochondriac region. The gastric pylorus (Choice B) is part of the stomach and is located more centrally in the abdomen. The spleen (Choice D) is located in the left upper quadrant of the abdomen, not underneath the right upper hypochondriac region.

2. Based on the documentation in the medical record, which action should the nurse implement next?

• A. Administer the rubella vaccine subcutaneously
• B. Observe the mother breastfeeding her infant
• C. Call the nursery for the infant's blood type result
• D. Administer Vicodin one tablet for pain

Correct answer: B

Rationale: The correct answer is to observe the mother breastfeeding her infant. This action is essential to ensure that the infant is feeding well and to assess maternal-infant bonding. Administering the rubella vaccine subcutaneously (Option A) is not the immediate priority in this scenario as assessing breastfeeding is more crucial. Calling the nursery for the infant's blood type result (Option C) is premature and not the next appropriate step, as it does not address the immediate needs of the newborn. Administering Vicodin one tablet for pain (Option D) is not indicated without further assessment or indication of pain, making it an incorrect choice at this time.

3. A client with a diagnosis of depression is prescribed an SSRI. What is the most important information the nurse should provide?

• A. Take the medication as prescribed.
• B. Avoid consuming grapefruit juice.
• C. Report any thoughts of self-harm immediately.
• D. Understand that improvement may take weeks.

Correct answer: C

Rationale: The most important information the nurse should provide to a client prescribed an SSRI for depression is to report any thoughts of self-harm immediately. SSRIs can increase suicidal ideation, especially at the beginning of treatment, so it is crucial to monitor for this and take appropriate actions. While it is important to take the medication as prescribed (Choice A), the immediate need for reporting self-harm ideation takes precedence. Avoiding grapefruit juice (Choice B) is a general precaution with certain medications but not as critical in this scenario. Understanding that improvement may take weeks (Choice D) is important for managing treatment expectations, but ensuring the client's safety in the context of suicidal ideation is the top priority.

4. The nurse is caring for a 75-year-old male client who is beginning to form a decubitus ulcer at the coccyx. Which intervention will be most helpful in preventing further development of the decubitus ulcer?

• A. Encourage the client to eat foods high in protein
• B. Assess the client for daily range of motion exercises
• C. Teach the family how to perform sterile wound care
• D. Ensure the IV fluids are administered as prescribed

Correct answer: A

Rationale: Encouraging the client to eat foods high in protein is crucial in preventing further development of decubitus ulcers as high protein foods support tissue repair and skin integrity. Adequate protein intake is essential for wound healing. Assessing the client for daily range of motion exercises is important for preventing complications related to immobility, but it may not directly address the prevention of decubitus ulcers. Teaching the family how to perform sterile wound care is significant for wound management but may not be the most effective intervention to prevent further development of decubitus ulcers. Ensuring IV fluids are administered as prescribed is essential for maintaining hydration status but is not the most relevant intervention for preventing decubitus ulcers.

5. What should the nurse prioritize when providing discharge instructions to a client with a new colostomy?

• A. Skin care around the stoma site
• B. The schedule for colostomy bag replacement
• C. Techniques for odor control
• D. Dietary modifications

Correct answer: A

Rationale: Correct answer: Skin care around the stoma site. Proper skin care around the stoma site is crucial for preventing skin irritation and infection, which are common issues for patients with new colostomies. While the schedule for colostomy bag replacement (Option B) is important, it is not the priority during initial discharge instructions. Techniques for odor control (Option C) are relevant but secondary to skin care for a new colostomy. Dietary modifications (Option D) may be discussed later but are not the priority at this stage.

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