Nursing Elites

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

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

Correct answer: B

Rationale: Confusion and altered mental status are concerning in a client with cirrhosis as they may indicate hepatic encephalopathy, a serious complication that requires immediate intervention. Increased abdominal girth can be seen in ascites, yellowing of the skin is due to jaundice, and peripheral edema is associated with fluid retention in cirrhosis, but confusion and altered mental status are more closely linked to hepatic encephalopathy, which can progress rapidly and needs urgent attention.

2. A client with end-stage renal disease (ESRD) is scheduled for hemodialysis. Which laboratory value should be reported to the healthcare provider before the procedure?

• A. Serum creatinine of 2.5 mg/dL
• B. Serum potassium of 6.5 mEq/L
• C. Serum calcium of 8 mg/dL
• D. Serum bicarbonate of 24 mEq/L

Correct answer: B

Rationale: The correct answer is B. A serum potassium level of 6.5 mEq/L is dangerously high and should be reported before hemodialysis to prevent cardiac complications. High potassium levels can lead to life-threatening arrhythmias. Serum creatinine (Choice A) is elevated in renal dysfunction but not the most critical value to report before hemodialysis. Serum calcium (Choice C) and serum bicarbonate (Choice D) levels are within normal limits and are not immediate concerns before hemodialysis.

3. Before a dressing change to his legs, which intervention is most important for the nurse to implement?

• A. Encourage the patient to stay at the bedside
• B. Use distraction techniques to reduce pain
• C. Maintain strict aseptic technique
• D. Place a drape over the burn area

Correct answer: C

Rationale: Maintaining strict aseptic technique is crucial before a dressing change for burn patients to prevent infection. Encouraging the patient to stay at the bedside, using distraction techniques, or placing a drape over the burn area are not as critical as ensuring asepsis in this situation.

4. A client with acute pancreatitis is receiving total parenteral nutrition (TPN). Which laboratory value should the nurse monitor closely?

• A. Serum potassium
• B. Serum glucose
• C. Serum triglycerides
• D. Serum calcium

Correct answer: C

Rationale: In a client with acute pancreatitis receiving total parenteral nutrition (TPN), the nurse should monitor serum triglycerides closely. Acute pancreatitis can lead to fat malabsorption, making the client susceptible to hypertriglyceridemia. Monitoring serum triglycerides is crucial to prevent complications such as hyperlipidemia. While monitoring serum potassium, glucose, and calcium levels is also essential in various conditions, in this scenario, the primary concern is the risk of developing hypertriglyceridemia due to fat malabsorption.

5. The nurse who is working on a surgical unit receives a change of shift report on a group of clients for the upcoming shift. A client with which condition requires the most immediate attention by the nurse?

• A. Gunshot wound three hours ago with dark drainage of 2 cm noted on the dressing.
• B. Mastectomy 2 days ago with 50 ml bloody drainage noted in the Jackson-Pratt drain.
• C. Collapsed lung after a fall 8 hours ago with 100 ml blood in the chest tube collection container
• D. Abdominal-perineal resection 2 days ago with no drainage on dressing who has fever and chills.

Correct answer: D

Rationale: The correct answer is D. A client who had an abdominal-perineal resection 2 days ago with no drainage on the dressing but is presenting with fever and chills requires immediate attention. This presentation raises concerns for peritonitis, a serious complication that necessitates prompt assessment and intervention to prevent further complications. Choices A, B, and C do not indicate an immediate risk for a life-threatening condition like peritonitis, making them lower priority compared to choice D.

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