Nursing Elites

1. The nurse is planning care for a 48-year-old woman with acute severe pancreatitis. The highest priority patient outcome is

• A. maintaining normal respiratory function.
• B. expressing satisfaction with pain control.
• C. developing no ongoing pancreatic disease.
• D. having adequate fluid and electrolyte balance.

Correct answer: A

Rationale: In acute severe pancreatitis, there is a risk of respiratory failure as a complication, making the maintenance of normal respiratory function the priority outcome. This patient may develop respiratory issues due to the inflammatory process affecting the diaphragm. While pain control, absence of ongoing pancreatic disease, and fluid/electrolyte balance are crucial, they are secondary to ensuring adequate oxygenation and ventilation to prevent respiratory compromise.

2. A 64-year-old patient with amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care?

• A. Assist with active range of motion (ROM).
• B. Observe for agitation and paranoia.
• C. Give muscle relaxants as needed to reduce spasms.
• D. Use simple words and phrases to explain procedures.

Correct answer: A

Rationale: In a patient with ALS, progressive muscle weakness is a significant issue. Assisting with active range of motion (ROM) exercises will help maintain muscle strength for as long as possible. Agitation and paranoia are not typically associated with ALS, making choice B incorrect. Giving muscle relaxants can further weaken muscles and depress respirations, worsening the condition, so choice C is inappropriate. Choice D is not directly related to the patient's physical condition and needs.

3. The healthcare provider is caring for a 20 lbs (9 kg) 6-month-old with a 3-day history of diarrhea, occasional vomiting, and fever. Peripheral intravenous therapy has been initiated, with 5% dextrose in 0.33% normal saline with 20 mEq of potassium per liter infusing at 35 ml/hr. Which finding should be reported to the healthcare provider immediately?

• A. 3 episodes of vomiting in 1 hour
• B. Periodic crying and irritability
• C. Vigorous sucking on a pacifier
• D. No measurable voiding in 4 hours

Correct answer: D

Rationale: The correct answer is 'No measurable voiding in 4 hours.' This finding should be reported to the healthcare provider immediately. The concern is the possibility of hyperkalemia, which could occur with continued potassium administration and a decrease in urinary output since potassium is excreted via the kidneys. It is crucial to monitor urinary output in pediatric patients receiving potassium-containing IV solutions to prevent electrolyte imbalances and potential complications. Choices A, B, and C are not the most critical findings that require immediate reporting. '3 episodes of vomiting in 1 hour' may suggest a need for antiemetic therapy or further assessment of the underlying cause but does not pose an immediate risk like the potential electrolyte imbalance from decreased urinary output. 'Periodic crying and irritability' and 'Vigorous sucking on a pacifier' are common behaviors in infants and are not indicative of a critical condition that requires urgent attention in this scenario.

4. The mother of a child with hepatitis A tells the home care nurse that she is concerned because the child's jaundice seems worse. What is the nurse's best response?

• A. You need to change the child's diet.
• B. The child probably is infectious again.
• C. The jaundice may worsen before it resolves.
• D. You need to call the primary health care provider.

Correct answer: C

Rationale: The best response for the nurse in this situation is to explain to the mother that jaundice may seem to worsen before it eventually gets better. This is a common occurrence in hepatitis A. Option A about changing the child's diet is irrelevant to the concern raised by the mother and not supported by evidence. Option B suggesting the child is infectious again is incorrect and may cause unnecessary alarm as jaundice does not indicate reinfection. Option D, advising the mother to call the primary health care provider, is premature as the nurse can first provide education and reassurance regarding the expected course of jaundice in hepatitis A.

5. The nurse recognizes that teaching a 44-year-old woman following a laparoscopic cholecystectomy has been effective when the patient states which of the following?

• A. I can expect yellow-green drainage from the incision for a few days.
• B. I can remove the bandages on my incisions tomorrow and take a shower.
• C. I should plan to limit my activities and not return to work for 4 to 6 weeks.
• D. I will always need to maintain a low-fat diet since I no longer have a gallbladder.

Correct answer: B

Rationale: The correct answer is, 'I can remove the bandages on my incisions tomorrow and take a shower.' After a laparoscopic cholecystectomy, patients have Band-Aids over the incisions and can typically remove the bandages the next day. Patients are usually discharged the same or next day and have minimal restrictions on their daily activities. Yellow-green drainage from the incision would be abnormal, requiring the patient to contact their healthcare provider. While a low-fat diet may be recommended initially after surgery, it is not a lifelong requirement, as the body can adjust to the absence of the gallbladder over time. Choice A is incorrect as abnormal drainage should be reported. Choice C is incorrect as most patients can resume normal activities within a few days to a week. Choice D is incorrect as maintaining a low-fat diet is not a lifelong necessity after a cholecystectomy.

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