Nursing Elites

1. A client with chronic kidney disease (CKD) is admitted with hyperkalemia. Which laboratory value is most concerning?

• A. Serum potassium of 6.5 mEq/L
• B. Serum sodium of 135 mEq/L
• C. Serum creatinine of 2.0 mg/dl
• D. Blood glucose of 150 mg/dl

Correct answer: A

Rationale: A serum potassium level of 6.5 mEq/L is concerning in a client with CKD as it indicates hyperkalemia, which requires immediate intervention to prevent cardiac complications. Hyperkalemia can lead to life-threatening arrhythmias, particularly in patients with impaired kidney function. Serum sodium, creatinine, and blood glucose levels, while important, are not as acutely dangerous as severe hyperkalemia in this context.

2. A client with heart failure is receiving digoxin (Lanoxin) and furosemide (Lasix). Which assessment finding requires immediate intervention?

• A. Heart rate of 60 beats per minute
• B. Apical pulse of 58 beats per minute
• C. Presence of a new murmur
• D. Blood pressure of 100/60 mmHg

Correct answer: C

Rationale: The correct answer is C. The presence of a new murmur in a client with heart failure receiving digoxin and furosemide is concerning as it may indicate valvular problems or other complications that require immediate intervention. A heart rate of 60 beats per minute and an apical pulse of 58 beats per minute are within normal limits for a client with heart failure on these medications. A blood pressure of 100/60 mmHg, while slightly low, may be expected due to the diuretic effect of furosemide and may not require immediate intervention unless the client is symptomatic.

3. A male client with impaired renal function who takes ibuprofen daily for chronic arthritis is showing signs of gastrointestinal (GI) bleeding. After administering IV fluids and a blood transfusion, his blood pressure is 100/70 mm Hg, and his renal output is 20 ml/hour. Which intervention should the nurse include in his care plan?

• A. Maintain the client NPO during the diuresis phase.
• B. Evaluate daily serial renal laboratory studies for progressive elevations.
• C. Observe the urine character for sedimentation and cloudy appearance.
• D. Monitor for the onset of polyuria greater than 150 ml/hour.

Correct answer: B

Rationale: In this scenario, the correct intervention for the nurse to include in the care plan is to evaluate daily serial renal laboratory studies for progressive elevations. This is crucial in monitoring renal function and detecting any worsening renal impairment. Option A is not directly related to managing renal function in this case. Option C focuses more on urinary characteristics rather than renal function monitoring. Option D addresses polyuria, which is an excessive urine output, but it does not specifically address the need for evaluating renal laboratory studies for progressive elevations.

4. 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.

5. A client who had a gestational trophoblastic disease (GTD) evacuated 2 days ago is being monitored for choriocarcinoma. She lives in a rural area, and her husband takes the family car to work daily, leaving her without transportation during the day. What intervention is most important for the nurse to implement?

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

Correct answer: B

Rationale: Scheduling weekly home visits to monitor hCG levels is critical for early detection of choriocarcinoma, a potential complication of GTD. Choice A is incorrect because a home pregnancy test is not the appropriate method to monitor for choriocarcinoma. Choice C is less frequent than necessary for close monitoring. Choice D is incorrect as chemotherapy administration should be based on confirmed diagnosis and treatment plan, not initiated during the first home visit.

Similar Questions