Nursing Elites

1. A client with chronic kidney disease is being assessed. Which of the following laboratory values would be most concerning?

• A. Serum creatinine of 3.0 mg/dL
• B. Serum potassium of 6.5 mEq/L
• C. Blood urea nitrogen (BUN) of 45 mg/dL
• D. Hemoglobin of 10 g/dL

Correct answer: B

Rationale: In a client with chronic kidney disease, elevated serum potassium levels (hyperkalemia) are the most concerning finding. Hyperkalemia can lead to life-threatening cardiac dysrhythmias. Monitoring and managing serum potassium levels are crucial in patients with kidney disease to prevent severe complications. While elevated creatinine (Choice A) and BUN (Choice C) are indicative of impaired kidney function, hyperkalemia poses a more immediate threat to the client's health. Hemoglobin levels (Choice D) can be affected by chronic kidney disease but are not as acutely dangerous as severe hyperkalemia.

2. A client is admitted with a diagnosis of Guillain-Barre syndrome. Which assessment finding is most concerning?

• A. Loss of reflexes in the legs
• B. Decreased peripheral sensation
• C. Respiratory distress
• D. Muscle weakness in the arms

Correct answer: C

Rationale: The correct answer is C: Respiratory distress. In Guillain-Barre syndrome, respiratory distress is the most concerning finding as it can indicate progression to respiratory failure, which is a life-threatening complication. Loss of reflexes in the legs and muscle weakness in the arms are common manifestations of the condition but may not be as immediately life-threatening as respiratory distress. Decreased peripheral sensation is also a common symptom but is not as critical as respiratory distress in terms of immediate patient safety and management.

3. A client who had a myocardial infarction (MI) 2 days ago has many questions about this condition. What area is a priority for the nurse to discuss at this time?

• A. Daily needs and concerns
• B. The overview of cardiac rehabilitation
• C. Medication and diet guidelines
• D. Activity and rest guidelines

Correct answer: A

Rationale: Addressing the client's daily needs and concerns is a priority to help alleviate anxiety and ensure the client understands the immediate post-MI care. Daily needs and concerns encompass basic aspects like comfort, hygiene, emotional support, and overall well-being, which are crucial in the early recovery phase post-MI. Discussing cardiac rehabilitation, medication and diet guidelines, or activity and rest guidelines are important topics but addressing immediate personal needs and concerns takes precedence to establish a supportive and informative care environment.

4. A client with a history of falls is under the care of a nurse. Which of the following actions should the nurse take to prevent falls?

• A. Keep the client's bed in the lowest position.
• B. Encourage the client to wear non-slip socks.
• C. Place a fall risk sign on the client's door.
• D. Use a gait belt when ambulating the client.

Correct answer: A

Rationale: Keeping the client's bed in the lowest position is an essential measure to prevent falls. Lowering the bed reduces the risk of injury if the client falls out of bed by decreasing the distance of the fall. Encouraging the client to wear non-slip socks (Choice B) may help prevent slips on smooth surfaces but does not address the risk of falls in other scenarios. Placing a fall risk sign on the client's door (Choice C) alone does not actively prevent falls but serves as a warning. Using a gait belt when ambulating the client (Choice D) is important for assisting with mobility but does not directly address fall prevention in the client's environment.

5. During an admission assessment of an older adult client, a nurse should identify which of the following findings as a potential indication of abuse?

• A. Bruises on the arms in various stages of healing
• B. Recent weight gain
• C. Complaints of joint pain
• D. Frequent visits to different providers

Correct answer: A

Rationale: Bruises on the arms in various stages of healing should be identified as a potential indication of abuse in an older adult. These bruises may suggest physical harm or neglect, which are concerning signs of abuse. Recent weight gain (Choice B) is not typically associated with abuse and can have various causes, such as dietary changes or health conditions. Complaints of joint pain (Choice C) are more likely related to musculoskeletal issues rather than abuse. Frequent visits to different providers (Choice D) could indicate seeking multiple opinions or healthcare needs and do not necessarily point to abuse.

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