Nursing Elites

1. In a client with cirrhosis admitted with ascites and jaundice, which clinical finding requires immediate intervention?

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

Correct answer: B

Rationale: Confusion and altered mental status in a client with cirrhosis and associated ascites and jaundice are indicative of hepatic encephalopathy, a serious complication that requires immediate intervention. This condition can progress rapidly and lead to coma if not addressed promptly. Peripheral edema (choice A) and increased abdominal girth (choice C) are common manifestations of fluid retention in cirrhosis but may not require immediate intervention unless severe. Yellowing of the skin (choice D) is a classic sign of jaundice, which is already known in this client and may not necessitate immediate intervention unless associated with other concerning symptoms.

2. The nurse is caring for a client with diabetic ketoacidosis (DKA). Which intervention is most important?

• A. Administer insulin as prescribed.
• B. Monitor the client's urine output.
• C. Assess the client's level of consciousness.
• D. Obtain an arterial blood gas (ABG) sample.

Correct answer: A

Rationale: Administering insulin is the most crucial intervention in managing diabetic ketoacidosis. Insulin helps reduce blood glucose levels and correct metabolic acidosis, which are the primary issues in DKA. Monitoring urine output (Choice B) is important but not as critical as administering insulin. Assessing the client's level of consciousness (Choice C) is essential but does not directly address the underlying cause of DKA. Obtaining an arterial blood gas sample (Choice D) can provide valuable information but is not as urgent as administering insulin to address the immediate metabolic imbalance.

3. Which instruction is most important for a client who receives a new plan of care to treat osteoporosis?

• A. Start a weight-bearing exercise plan.
• B. Increase consumption of foods rich in calcium.
• C. Arrange a bone density test every year.
• D. Stay upright after taking the medication.

Correct answer: D

Rationale: The correct answer is D: 'Stay upright after taking the medication.' This instruction is crucial for clients receiving medications like bisphosphonates to prevent esophageal irritation or erosion. While weight-bearing exercises (choice A) are important for bone health, staying upright after medication intake takes precedence. Increasing calcium-rich foods (choice B) is beneficial but not the most important immediate instruction. Scheduling bone density tests (choice C) is necessary for monitoring osteoporosis but is not as critical as staying upright after medication.

4. A client with diabetes mellitus is admitted with a blood glucose level of 600 mg/dl and is unresponsive. Which laboratory value is most concerning?

• A. Serum potassium of 3.0 mEq/L
• B. Serum glucose of 200 mg/dl
• C. Serum pH of 7.30
• D. Serum sodium of 135 mEq/L

Correct answer: C

Rationale: In a client with Hyperosmolar Hyperglycemic State (HHS), a serum pH of 7.30 is the most concerning value as it indicates acidosis, a life-threatening condition that requires immediate intervention. Choices A, B, and D are not the most concerning in this scenario. A low serum potassium level (Choice A) may be expected due to cellular shift in hyperglycemia, a serum glucose level of 200 mg/dl (Choice B) is not as concerning compared to the extremely high initial glucose level, and a serum sodium level of 135 mEq/L (Choice D) is within the normal range and not the immediate priority.

5. The nurse is caring for a client with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation. Which assessment finding requires immediate intervention?

• A. Oxygen saturation of 90%
• B. Respiratory rate of 28 breaths per minute
• C. Tidal volume of 300 ml
• D. Blood pressure of 110/70 mmHg

Correct answer: C

Rationale: The correct answer is C. A tidal volume of 300 ml is concerning in a client with ARDS on mechanical ventilation because it indicates hypoventilation, which can lead to inadequate gas exchange and worsening respiratory status. This finding requires immediate intervention to optimize ventilation and oxygenation. Options A, B, and D are not as critical in this scenario. An oxygen saturation of 90% may be acceptable depending on the client's baseline condition and the target range set by the healthcare provider. A respiratory rate of 28 breaths per minute is slightly elevated but may not be immediately alarming. A blood pressure of 110/70 mmHg is within normal limits and does not require urgent intervention.

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