Nursing Elites

1. A client with chronic kidney disease (CKD) is receiving erythropoietin therapy. Which laboratory value should the nurse monitor closely?

• A. Serum potassium
• B. Hemoglobin
• C. White blood cell count
• D. Serum creatinine

Correct answer: A

Rationale: The correct answer is A: Serum potassium. When a client with chronic kidney disease is receiving erythropoietin therapy, monitoring serum potassium closely is essential. Erythropoietin therapy can lead to increased red blood cell production, which may cause potassium levels to rise, potentially resulting in hyperkalemia. Monitoring potassium levels helps prevent complications associated with hyperkalemia. Choices B, C, and D are incorrect because they are not directly impacted by erythropoietin therapy in the context of CKD.

2. The nurse is caring for a client who is postoperative following a thyroidectomy. Which assessment finding is most concerning?

• A. Slight difficulty swallowing
• B. Hoarse voice
• C. Positive Chvostek's sign
• D. Pain at the incision site

Correct answer: C

Rationale: A positive Chvostek's sign is the most concerning assessment finding as it suggests hypocalcemia, which is a potential complication following thyroidectomy. Hypocalcemia can lead to serious complications such as tetany and laryngospasm. Immediate intervention is required to prevent further complications. Choices A, B, and D are common post-thyroidectomy findings and are expected during the immediate postoperative period. Slight difficulty swallowing may be due to postoperative swelling, a hoarse voice may be temporary due to intubation trauma, and pain at the incision site is normal after surgery.

3. A client with type 1 diabetes is admitted with diabetic ketoacidosis (DKA). Which clinical finding requires immediate intervention?

• A. Serum glucose of 300 mg/dL
• B. Serum potassium of 5.5 mEq/L
• C. Serum bicarbonate of 18 mEq/L
• D. Positive urine ketones

Correct answer: C

Rationale: A serum bicarbonate level of 18 mEq/L indicates metabolic acidosis in a client with DKA, requiring immediate intervention. In DKA, the body produces excess ketones, leading to metabolic acidosis, which is reflected by a low serum bicarbonate level. Correcting the low serum bicarbonate is crucial to normalize the metabolic acidosis and improve the client's condition. While elevated serum glucose (choice A) and urine ketones (choice D) are characteristic of DKA, addressing the metabolic acidosis takes precedence. Serum potassium (choice B) levels may also need monitoring and management, but correcting the acidosis is the priority to prevent complications like cardiovascular collapse.

4. When caring for a client with traumatic brain injury (TBI) who had a craniotomy for increased intracranial pressure (ICP), the nurse assesses the client using the Glasgow Coma Scale (GCS) every two hours. For the past 8 hours, the client's GCS score has been 14. What does this GCS finding indicate about the client?

• A. Neurologically stable without indications of increased ICP.
• B. At risk for neurological deterioration.
• C. Experiencing mild cognitive impairment.
• D. In need of immediate medical intervention.

Correct answer: A

Rationale: A GCS score of 14 indicates that the client is neurologically stable without indications of increased ICP. It suggests that the client's neurological status is relatively intact, with only mild impairment, if any. This finding reassures the nurse that there are currently no signs of deterioration or immediate need for intervention. Choice B is incorrect because a GCS score of 14 does not necessarily indicate immediate risk for neurological deterioration. Choice C is incorrect as mild cognitive impairment is not typically inferred from a GCS score of 14. Choice D is incorrect as immediate medical intervention is not warranted based on a GCS score of 14 without other concerning symptoms.

5. A client is receiving a full-strength continuous enteral tube feeding at 50 ml/hour and has developed diarrhea. The client has a new prescription to change the feeding to half strength. What intervention should the nurse implement?

• A. Add equal amounts of water and feeding to a feeding bag and infuse at 50 ml/hour
• B. Continue the full-strength feeding after decreasing the rate of infusion to 25 ml/hour
• C. Maintain the present feeding until diarrhea subsides and then begin the new prescription
• D. Withhold any further feeding until clarifying the prescription with the healthcare provider

Correct answer: A

Rationale: The correct intervention is to dilute the formula by adding equal amounts of water and feeding to a feeding bag and infusing it at 50 ml/hour. This can help alleviate the diarrhea that has developed. Diarrhea can occur as a complication of enteral tube feeding and can be due to a variety of causes, including hyperosmolar formula. Choice B is incorrect as continuing the full-strength feeding, even at a lower rate, may not address the issue of diarrhea. Choice C is incorrect because it is important to follow the new prescription to manage the diarrhea effectively. Choice D is incorrect as withholding feeding without taking appropriate action may delay necessary intervention.

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