Nursing Elites

1. A 23-year-old has been admitted with acute liver failure. Which assessment data are most important for the nurse to communicate to the healthcare provider?

• A. Asterixis and lethargy
• B. Jaundiced sclera and skin
• C. Elevated total bilirubin level
• D. Liver 3 cm below costal margin

Correct answer: A

Rationale: The most critical assessment data for the nurse to communicate to the healthcare provider in a patient with acute liver failure are asterixis and lethargy. These findings are indicative of grade 2 hepatic encephalopathy, which signals a rapid deterioration in the patient's condition, necessitating early transfer to a transplant center. Jaundiced sclera and skin, elevated total bilirubin level, and a liver 3 cm below the costal margin are all typical findings in hepatic failure but do not indicate an immediate need for a change in the therapeutic plan. Therefore, while these findings are relevant and should be reported, they are not as urgent as asterixis and lethargy in a patient with acute liver failure.

2. A patient has acute bronchitis with a nonproductive cough and wheezes. Which topic should the nurse plan to include in the teaching plan?

• A. Purpose of antibiotic therapy
• B. Ways to limit oral fluid intake
• C. Appropriate use of cough suppressants
• D. Safety concerns with home oxygen therapy

Correct answer: C

Rationale: In acute bronchitis, which is often viral, cough suppressants can help manage the symptoms of a nonproductive cough. Antibiotics are not typically used in acute bronchitis unless there are systemic symptoms indicating a bacterial infection. Limiting oral fluid intake is not recommended; in fact, maintaining adequate hydration is important. Safety concerns with home oxygen therapy may not be directly relevant to the management of acute bronchitis.

3. A patient with severe mitral regurgitation and decreased cardiac output is being cared for by a nurse. The nurse assesses the patient for mental status changes. What is the rationale for this intervention?

• A. Decreased cardiac output can cause hypoxia to the brain
• B. Mental status changes may be a side effect of the patient's medication
• C. Mitral regurgitation is a complication associated with some neurological disorders
• D. The patient may be confused about his diagnosis

Correct answer: A

Rationale: When caring for a patient with severe mitral regurgitation and decreased cardiac output, assessing for mental status changes is crucial. Decreased cardiac output can lead to inadequate perfusion and oxygenation of vital organs, including the brain, resulting in hypoxia. This hypoxia can manifest as mental status changes such as confusion, restlessness, or lethargy. Therefore, monitoring mental status helps in identifying potential hypoxic states and guiding appropriate interventions. The other options are incorrect as they do not directly correlate decreased cardiac output with potential hypoxia-induced mental status changes.

4. While planning care for a 2-year-old hospitalized child, which situation would the nurse expect to most likely affect the behavior?

• A. Strange bed and surroundings
• B. Separation from parents
• C. Presence of other toddlers
• D. Unfamiliar toys and games

Correct answer: B

Rationale: The correct answer is 'Separation from parents.' Separation anxiety is most evident from 6 months to 30 months of age and is the greatest stress imposed on a toddler by hospitalization. If separation is avoided, young children have a tremendous capacity to withstand other stress. The other choices, such as 'Strange bed and surroundings,' 'Presence of other toddlers,' and 'Unfamiliar toys and games,' may also have an impact on the child, but separation from parents is typically the most significant factor affecting behavior in a hospitalized 2-year-old.

5. The nurse cares for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider?

• A. Oxygen saturation is 88%.
• B. Blood pressure is 145/90 mm Hg.
• C. Respiratory rate is 22 breaths/minute when lying flat.
• D. Pain level is 5 (on a 0 to 10 scale) with a deep breath.

Correct answer: A

Rationale: The correct answer is 'Oxygen saturation is 88%.' Following a thoracentesis, oxygen saturation should improve. A saturation of 88% suggests a potential complication like pneumothorax. While the other assessment findings are important, the priority is to address the low oxygen saturation to prevent further complications. High blood pressure and respiratory rate may also need attention, but the immediate concern is the oxygen saturation level. Pain level, though significant for the patient's comfort, takes lower priority compared to the potential life-threatening issue of hypoxia.

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