Nursing Elites

1. To evaluate the client's therapeutic response to lactulose for signs of hepatic encephalopathy, which assessment should the nurse obtain?

• A. Level of consciousness
• B. Percussion of abdomen
• C. Serum electrolytes
• D. Blood glucose

Correct answer: A

Rationale: The correct answer is A: Level of consciousness. Monitoring the client's level of consciousness is essential in evaluating the effectiveness of lactulose in treating hepatic encephalopathy. Lactulose helps reduce blood ammonia levels by promoting the excretion of ammonia in the stool, thereby improving the client's mental status. Assessing the client's level of consciousness helps determine if the medication is effectively managing hepatic encephalopathy symptoms. Choices B, percussion of the abdomen, and D, blood glucose, are not directly related to evaluating the therapeutic response to lactulose for hepatic encephalopathy. Choice C, serum electrolytes, while important in overall patient care, is not the primary assessment to determine lactulose's effectiveness in treating hepatic encephalopathy.

2. A client with renal disease seems anxious and presents with the onset of shortness of breath, lethargy, edema, and weight gain. Which action should the nurse implement first?

• A. Determine serum potassium level
• B. Calculate the client’s daily fluid intake
• C. Assess client for signs of vertigo
• D. Review the client’s pulse oximetry reading

Correct answer: A

Rationale: The correct answer is to determine the client's serum potassium level. In a client with renal disease experiencing symptoms like shortness of breath, lethargy, edema, and weight gain, assessing serum potassium levels is crucial. Electrolyte imbalances, including potassium, can lead to serious complications such as cardiac arrhythmias and muscle weakness. Calculating daily fluid intake may be important but addressing acute symptoms related to electrolyte imbalances takes precedence. Assessing for signs of vertigo and reviewing pulse oximetry reading are not the priority in this scenario compared to assessing and managing potential electrolyte imbalances.

3. For a client with pneumonia, the prescription states, “Oxygen at liters/min per nasal cannula PRN difficult breathing.” Which nursing intervention is effective in preventing oxygen toxicity?

• A. Avoiding the administration of oxygen at high levels for extended periods.
• B. Administering a sedative at bedtime to slow the client’s respiratory rate.
• C. Removing the nasal cannula during the night to prevent oxygen buildup.
• D. Running oxygen through a hydration source prior to administration.

Correct answer: A

Rationale: Choice A is the correct answer because prolonged exposure to high levels of oxygen can lead to oxygen toxicity. Administering oxygen at high levels for extended periods can overwhelm the body's natural defenses against high oxygen levels, causing toxicity. Choices B, C, and D are incorrect. Choice B is unrelated to preventing oxygen toxicity. Choice C is unsafe as removing the nasal cannula can deprive the client of necessary oxygen. Choice D, running oxygen through a hydration source, is not a standard practice for preventing oxygen toxicity.

4. After a motor vehicle collision, a client is admitted to the medical unit with acute adrenal insufficiency (Addisonian crisis). Which prescription should the nurse implement?

• A. Determine serum glucose levels
• B. Withhold potassium additives to IV fluids
• C. Give IV corticosteroid replacement
• D. Prepare to initiate IV vasopressors

Correct answer: C

Rationale: In a client with acute adrenal insufficiency (Addisonian crisis) following a motor vehicle collision, the priority intervention is to administer IV corticosteroid replacement. This is crucial to manage the crisis by replacing the deficient cortisol. Determining serum glucose levels (Choice A) may be important but is not the immediate priority in this situation. Withholding potassium additives to IV fluids (Choice B) is not indicated and may exacerbate electrolyte imbalances. Initiating IV vasopressors (Choice D) is not the primary treatment for acute adrenal insufficiency and should be reserved for managing hypotension that is unresponsive to corticosteroid therapy.

5. A heparin infusion is prescribed for a client who weighs 220 pounds. After administering a bolus dose of 80 units/kg, the nurse calculates the infusion rate for the heparin sodium at 18 units/kg/hour. The available solution is Heparin Sodium 25,000 units in 5% Dextrose Injection 250 ml. The nurse should program the infusion pump to deliver how many ml/hour?

• A. 18
• B. 27
• C. 36
• D. 45

Correct answer: B

Rationale: To calculate the infusion rate, first, find the total dose required per hour, which is the patient's weight (220 pounds) multiplied by the prescribed rate (18 units/kg/hour). This equals 3960 units/hour. Next, determine how many ml of the solution contain 25,000 units; this is 250 ml. Divide the total dose required per hour (3960 units) by the units per ml (25,000 units/250 ml) to find how many ml are needed per hour. This results in 27 ml/hour. Therefore, the nurse should program the infusion pump to deliver 27 ml/hour. Choice A (18) is incorrect as it does not account for the concentration of the heparin solution. Choices C (36) and D (45) are incorrect as they do not reflect the accurate calculations based on the patient's weight and the heparin concentration in the solution.

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