Nursing Elites

1. A 59-year-old male client comes to the clinic and reports his concern over a lump that 'just popped up on my neck about a week ago.' In performing an examination of the lump, the nurse palpates a large, nontender, hardened left subclavian lymph node. There is no overlying tissue inflammation. What do these findings suggest?

• A. Malignancy
• B. Infection
• C. Benign cyst
• D. Lymphadenitis

Correct answer: A

Rationale: The correct answer is A: Malignancy. A large, non-tender, hardened lymph node is a typical sign of malignancy and warrants further investigation. Choice B (Infection) is incorrect because typically in infections, lymph nodes are tender and may show signs of inflammation. Choice C (Benign cyst) is incorrect as a benign cyst would usually present as a soft, mobile lump. Choice D (Lymphadenitis) is incorrect as lymphadenitis usually presents with tender and enlarged lymph nodes due to inflammation.

2. A client with cirrhosis is admitted with jaundice and ascites. Which laboratory value requires immediate intervention?

• A. Serum albumin of 3.0 g/dL
• B. Serum bilirubin of 3.0 mg/dL
• C. Serum ammonia level of 80 mcg/dL
• D. Serum sodium level of 135 mEq/L

Correct answer: C

Rationale: A serum ammonia level of 80 mcg/dL is most concerning in a client with cirrhosis as it may indicate hepatic encephalopathy, requiring immediate intervention. High serum ammonia levels can lead to altered mental status, confusion, and even coma. Serum albumin (choice A) is often decreased in cirrhosis but does not require immediate intervention. Serum bilirubin (choice B) elevation is expected in cirrhosis and may not require immediate intervention unless very high. Serum sodium (choice D) within the given range is generally acceptable and does not require immediate intervention.

3. A client with a history of atrial fibrillation is admitted with a new onset of confusion. Which laboratory value should the nurse monitor closely?

• A. International Normalized Ratio (INR)
• B. Serum glucose level
• C. White blood cell count
• D. Prothrombin time (PT)

Correct answer: A

Rationale: The correct answer is A: International Normalized Ratio (INR). The INR should be closely monitored in a client with atrial fibrillation to assess the effectiveness and safety of anticoagulation therapy with warfarin. Monitoring the INR helps to ensure that the client is within the therapeutic range to prevent complications such as thrombosis or bleeding. Choices B, C, and D are less relevant in this scenario. While serum glucose levels are important in assessing metabolic status, and white blood cell count and prothrombin time are important indicators for other conditions, they are not the primary focus when a client with atrial fibrillation presents with confusion.

4. A client with a spinal cord injury is admitted to the ICU. Which nursing intervention is most important to include in this client's plan of care?

• A. Monitor for signs of autonomic dysreflexia.
• B. Implement measures to prevent pressure ulcers.
• C. Perform passive range of motion exercises.
• D. Ensure that the client is turned every two hours.

Correct answer: A

Rationale: The correct answer is A: Monitor for signs of autonomic dysreflexia. Autonomic dysreflexia is a life-threatening condition that can occur in clients with spinal cord injuries, especially those with injuries above the T6 level. It is characterized by a sudden onset of excessively high blood pressure, pounding headache, profuse sweating, and flushing above the level of injury. Failure to recognize and treat autonomic dysreflexia promptly can lead to seizures, stroke, or even death. Therefore, monitoring for signs of autonomic dysreflexia is crucial in clients with spinal cord injuries. Choices B, C, and D are important interventions too, but in the context of a spinal cord injury, monitoring for autonomic dysreflexia takes priority due to its potentially life-threatening nature.

5. In assessing a client 48 hours following a fracture, the nurse observes ecchymosis at the fracture site and recognizes that hematoma formation at the bone fragment site has occurred. What action should the nurse implement?

• A. Document the extent of the bruising in the medical record.
• B. Apply a cold compress to the area.
• C. Elevate the affected limb.
• D. Notify the healthcare provider.

Correct answer: A

Rationale: After observing ecchymosis at the fracture site, indicating hematoma formation, the nurse's priority is to document the extent of the bruising in the medical record. This documentation helps track the client's condition, aids in treatment planning, and serves as a baseline for monitoring changes. Applying a cold compress (choice B) may be contraindicated due to the risk of vasoconstriction and potential tissue damage. Elevating the affected limb (choice C) can be beneficial for reducing swelling in some cases, but documenting the bruising is the immediate concern. Notifying the healthcare provider (choice D) is not necessary at this stage unless there are other concerning symptoms or complications beyond the hematoma formation.

Similar Questions