Nursing Elites

1. A client with cirrhosis is admitted with jaundice and ascites. Which assessment finding is most concerning?

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

Correct answer: C

Rationale: In a client with cirrhosis presenting with jaundice and ascites, yellowing of the skin (icterus) is the most concerning assessment finding. This indicates significant liver dysfunction and a high level of bilirubin in the blood. Yellowing of the skin suggests a severe impairment of the liver's ability to process bilirubin, which can lead to serious complications. Peripheral edema and increased abdominal girth are common manifestations of cirrhosis but are not as acutely concerning as skin yellowing. Confusion and altered mental status are also critical findings in cirrhosis, indicating hepatic encephalopathy, but skin yellowing is more closely associated with the severity of liver dysfunction in this scenario.

2. A client with diabetes mellitus is admitted with a blood glucose level of 600 mg/dl and is unresponsive. Which intervention should the nurse implement first?

• A. Administer 50% dextrose IV push
• B. Administer IV fluids as prescribed
• C. Check the client's blood glucose level
• D. Prepare the client for immediate dialysis

Correct answer: B

Rationale: Administering IV fluids as prescribed should be the first intervention for a client with diabetes mellitus admitted with a blood glucose level of 600 mg/dl and unresponsive. This intervention is crucial in managing hyperglycemia by helping to correct dehydration and electrolyte imbalances. Administering 50% dextrose IV push (Choice A) would worsen hyperglycemia in this scenario. Checking the client's blood glucose level (Choice C) is important but not the priority when dealing with an unresponsive client with severe hyperglycemia. Immediate dialysis preparation (Choice D) is not indicated as the first intervention for hyperglycemia.

3. A client with pneumonia has arterial blood gases levels at: pH 7.33; PaCO2 49 mm/Hg; HCO3 25 mEq/L; PaO2 95. What intervention should the nurse implement based on these results?

• A. Institute coughing and deep breathing protocols.
• B. Administer oxygen via nasal cannula.
• C. Prepare for intubation and mechanical ventilation.
• D. Increase IV fluids to improve hydration.

Correct answer: A

Rationale: The ABG results indicate respiratory acidosis due to an elevated PaCO2 (49 mm/Hg), indicating hypoventilation. The appropriate intervention for respiratory acidosis is to improve ventilation. Coughing and deep breathing protocols can help the client to effectively ventilate and improve gas exchange. Administering oxygen via nasal cannula (Choice B) may be necessary in respiratory distress situations, but addressing the underlying cause of hypoventilation is crucial. Intubation and mechanical ventilation (Choice C) are not the first-line interventions for uncomplicated respiratory acidosis. Increasing IV fluids (Choice D) does not directly address the respiratory acidosis present in this scenario.

4. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which finding requires immediate intervention?

• A. Oxygen saturation of 90%
• B. Respiratory rate of 24 breaths per minute
• C. Use of accessory muscles
• D. Blood pressure of 110/70 mmHg

Correct answer: C

Rationale: The correct answer is C. The use of accessory muscles indicates increased work of breathing and may signal respiratory failure in a client with COPD, requiring immediate intervention. Oxygen saturation of 90% is within an acceptable range for COPD patients on supplemental oxygen. A respiratory rate of 24 breaths per minute is slightly elevated but not an immediate concern. A blood pressure of 110/70 mmHg is within the normal range and does not require immediate intervention in this scenario.

5. Following a gunshot wound to the abdomen, a young adult male had an emergency bowel resection and received multiple blood products. His current blood pressure is 78/52 mm Hg, and he is being mechanically ventilated. His oxygen saturation is 87%. Laboratory values indicate hemoglobin of 7 g/dL, platelets of 20,000/mm³, and white blood cells of 2,000/mm³. Which intervention should the nurse implement first?

• A. Transfuse packed red blood cells.
• B. Obtain blood and sputum cultures.
• C. Infuse 1000 ml of normal saline.
• D. Titrate oxygen to keep O2 saturation above 90%.

Correct answer: A

Rationale: The correct answer is to transfuse packed red blood cells first. The client's low hemoglobin level of 7 g/dL indicates severe anemia, which requires immediate transfusion to increase oxygen-carrying capacity. While obtaining blood and sputum cultures (Choice B) is important to identify potential infections, addressing the critical issue of anemia takes precedence. Infusing normal saline (Choice C) may help with volume status but does not address the primary concern of low hemoglobin. Titration of oxygen (Choice D) is crucial, but transfusion to improve oxygen-carrying capacity should be the priority in this scenario.

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