Nursing Elites

1. A client who had a gestational trophoblastic disease (GTD) evacuated 2 days ago is being... What intervention is most important for the nurse to implement?

• A. Teach the client about the use of a home pregnancy test.
• B. Schedule weekly home visits to draw hCG values.
• C. Schedule a 5-week follow-up with the healthcare provider.
• D. Begin chemotherapy administration during the first home visit.

Correct answer: B

Rationale: The most important intervention for the nurse to implement is to schedule weekly home visits to draw hCG values. Monitoring hCG levels is crucial in detecting potential complications like choriocarcinoma following GTD evacuation. Teaching about home pregnancy tests (Choice A) may not be as immediate and critical as monitoring hCG levels. A 5-week follow-up appointment (Choice C) may be too delayed for close monitoring. Initiating chemotherapy (Choice D) without appropriate hCG monitoring and evaluation is not recommended as the first-line intervention.

2. What is the first action the nurse should implement for a client admitted with acute pancreatitis?

• A. Administer intravenous fluids as prescribed
• B. Administer pain medication as prescribed
• C. Place the client on NPO status
• D. Assess the client's abdomen for distention

Correct answer: C

Rationale: Placing the client on NPO status is the priority action for a client with acute pancreatitis. This step is crucial to rest the pancreas, prevent pancreatic stimulation, and decrease enzyme production. By withholding oral intake, the digestive system is given a chance to rest and recover. Administering intravenous fluids may be necessary but should come after placing the client on NPO status. Pain medication can be administered once the client is stabilized. Assessing the client's abdomen for distention is important but is not the initial priority in managing acute pancreatitis.

3. A client with chronic liver disease is admitted with ascites and jaundice. Which assessment finding is most concerning?

• A. Enlarged spleen
• B. Increased abdominal girth
• C. Yellowing of the skin
• D. Confusion and altered mental status

Correct answer: D

Rationale: Confusion and altered mental status are concerning in a client with chronic liver disease, as they may indicate hepatic encephalopathy, a serious complication that requires immediate intervention. Enlarged spleen (choice A) can be a common finding in liver disease due to portal hypertension but may not be as acute as hepatic encephalopathy. Increased abdominal girth (choice B) is typically seen in ascites, which is already present in this client. Yellowing of the skin (choice C) is a manifestation of jaundice, also a known symptom in liver disease but not as acute as confusion and altered mental status.

4. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which finding indicates the need for immediate intervention?

• A. Use of accessory muscles
• B. Oxygen saturation of 94%
• C. Carbon dioxide level of 45 mmHg
• D. Respiratory rate of 20 breaths per minute

Correct answer: C

Rationale: A carbon dioxide level of 45 mmHg is concerning in a client with COPD receiving supplemental oxygen, as it may indicate carbon dioxide retention and requires immediate intervention. Options A, B, and D are not the priority findings in this scenario. While the use of accessory muscles, an oxygen saturation of 94%, and a respiratory rate of 20 breaths per minute are important to monitor in a client with COPD, they do not indicate an immediate need for intervention like an elevated carbon dioxide level does.

5. A client is admitted with a diagnosis of diabetic ketoacidosis (DKA). Which clinical finding is most concerning to the nurse?

• A. Kussmaul respirations
• B. Blood glucose level of 300 mg/dl
• C. Serum potassium of 3.2 mEq/L
• D. Positive urine ketones

Correct answer: C

Rationale: The correct answer is C: Serum potassium of 3.2 mEq/L. A low serum potassium level in a client with DKA is concerning due to the risk of cardiac arrhythmias. Kussmaul respirations (choice A) are a compensatory mechanism for metabolic acidosis in DKA. A blood glucose level of 300 mg/dl (choice B) is elevated but expected in DKA. Positive urine ketones (choice D) are a classic finding in DKA and not as concerning as low serum potassium.

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