Nursing Elites

1. The nurse is teaching an 87-year-old client methods for maintaining regular bowel movements. The nurse would caution the client to AVOID

• A. Glycerin suppositories
• B. Fiber supplements
• C. Laxatives
• D. Stool softeners

Correct answer: C

Rationale: The correct answer is C: Laxatives. Laxatives can be harsh on elderly clients, leading to dependence and potential side effects. While fiber supplements (B) and stool softeners (D) are generally safe options to promote regular bowel movements, laxatives should be used cautiously in older adults due to their potential risks. Glycerin suppositories (A) can also be a safe and effective option for managing constipation in the elderly, but laxatives should be avoided unless deemed necessary by a healthcare provider.

2. A client has a history of chronic obstructive pulmonary disease (COPD). As the nurse enters the client's room, the oxygen is running at 6 liters per minute, the client's color is flushed, and his respirations are 8 per minute. What should the nurse do first?

• A. Obtain a 12-lead EKG
• B. Place the client in high Fowler's position
• C. Lower the oxygen rate
• D. Take baseline vital signs

Correct answer: C

Rationale: In a client with COPD, it is crucial to prevent carbon dioxide retention by avoiding high oxygen levels. As the client's oxygen is running at 6 liters per minute and he is showing signs of oxygen toxicity, such as flushed color and low respirations, the nurse's priority should be to lower the oxygen rate. This action helps prevent worsening the client's condition. Obtaining an EKG, placing the client in high Fowler's position, or taking baseline vital signs are important assessments but addressing the potential oxygen toxicity takes precedence in this scenario.

3. The nurse is caring for a client with liver cirrhosis. Which of these findings would indicate that the client is experiencing complications of the disease?

• A. Yellowing of the skin and eyes
• B. Presence of spider angiomas on the skin
• C. Ascites and peripheral edema
• D. Clay-colored stools and dark urine

Correct answer: D

Rationale: Clay-colored stools and dark urine are classic signs of liver dysfunction, indicating bile flow obstruction commonly seen in liver cirrhosis. This finding is a significant complication requiring immediate medical evaluation. Yellowing of the skin and eyes (jaundice) is a common symptom of liver dysfunction but is not specific to complications. Spider angiomas and ascites with peripheral edema are also associated with liver cirrhosis, but they are not indicative of immediate complications as clay-colored stools and dark urine are.

4. A nurse is reinforcing teaching with a client who has constipation about a high-fiber diet. Which of the following foods should be included as sources of fiber? Select one that doesn't apply.

• A. Kidney beans
• B. Strawberries
• C. Peanut butter
• D. Whole wheat bread

Correct answer: C

Rationale: The correct answer is C, Peanut butter. While kidney beans, strawberries, and whole wheat bread are high-fiber foods that help alleviate constipation, peanut butter is not a significant source of fiber. Peanut butter is more known for its protein and healthy fats content rather than being a good source of dietary fiber. Therefore, it should not be included as a primary recommendation for a high-fiber diet in the context of addressing constipation.

5. A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse do first?

• A. Institute seizure precautions
• B. Monitor neurologic status every hour
• C. Place in respiratory/secretion precautions
• D. Cefotaxime IV 50 mg/kg/day divided q6h

Correct answer: C

Rationale: The correct answer is to place the child in respiratory/secretion precautions first. Meningococcal meningitis is highly contagious, and respiratory precautions are essential to prevent the spread of the infection. Seizure precautions may be necessary but are not the priority upon admission. Monitoring neurologic status is important but not the initial action needed. While antibiotic therapy like Cefotaxime is crucial, implementing isolation precautions to prevent transmission takes precedence in this situation.

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