Nursing Elites

1. A client with cirrhosis is admitted with jaundice and ascites. Which intervention should the nurse implement first?

• A. Administer a diuretic as prescribed.
• B. Administer lactulose as prescribed.
• C. Monitor the client's weight daily.
• D. Assess the client's neurological status.

Correct answer: B

Rationale: Administering lactulose is the first priority in managing a client with cirrhosis to reduce ammonia levels and prevent worsening hepatic encephalopathy. Lactulose helps in decreasing the absorption of ammonia in the intestines and promotes its excretion through the stool. This intervention is crucial in preventing the development or progression of hepatic encephalopathy. Administering a diuretic (Choice A) may be necessary to manage ascites, but it is not the priority over lactulose in this scenario. Monitoring the client's weight (Choice C) is important to assess fluid retention but is not the first intervention required. Assessing the client's neurological status (Choice D) is essential in cirrhosis, but administering lactulose takes precedence to prevent hepatic encephalopathy.

2. A client with liver cirrhosis and ascites is admitted with jaundice. Which laboratory value is most concerning to the nurse?

• A. Serum albumin of 3.0 g/dl
• B. Bilirubin of 3.0 mg/dl
• C. Ammonia level of 80 mcg/dl
• D. Prothrombin time of 18 seconds

Correct answer: C

Rationale: An ammonia level of 80 mcg/dl is elevated and concerning in a client with liver cirrhosis, as it may indicate hepatic encephalopathy. Elevated ammonia levels can lead to neurological symptoms such as confusion, altered mental status, and even coma. Serum albumin, bilirubin, and prothrombin time are important in liver cirrhosis but are not the most concerning for acute neurological deterioration associated with hepatic encephalopathy.

3. A client who is at 36 weeks gestation is admitted with severe preeclampsia. After a 6-gram loading dose of magnesium sulfate is administered, an intravenous infusion of magnesium sulfate at a rate of 2 grams/hour is initiated. Which assessment finding warrants immediate intervention by the nurse?

• A. Urine output of 20 ml/hour
• B. Blood pressure of 138/88
• C. Respiratory rate of 18 breaths/min
• D. Temperature of 99.8°F

Correct answer: A

Rationale: A urine output of less than 30 ml/hour indicates that the kidneys are being affected by the high level of magnesium sulfate. This decreased urine output can lead to magnesium toxicity and impaired kidney function. Blood pressure of 138/88 is within normal limits for pregnancy and does not indicate an immediate concern related to magnesium sulfate. A respiratory rate of 18 breaths/min is normal, and a temperature of 99.8°F is slightly elevated but not a priority in the context of severe preeclampsia and magnesium sulfate administration.

4. A client with type 1 diabetes is admitted with diabetic ketoacidosis (DKA). Which laboratory value 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. Serum sodium of 135 mEq/L

Correct answer: C

Rationale: A serum bicarbonate level of 18 mEq/L requires immediate intervention in a client with diabetic ketoacidosis (DKA). A low serum bicarbonate level indicates metabolic acidosis, which can be life-threatening. This condition needs urgent correction to restore acid-base balance. Serum glucose of 300 mg/dl, serum potassium of 5.5 mEq/L, and serum sodium of 135 mEq/L are abnormal values, but they do not pose an immediate threat to the client's life compared to the metabolic acidosis indicated by the low serum bicarbonate level.

5. A client with a traumatic brain injury becomes progressively less responsive to stimuli. The client has a 'Do Not Resuscitate' prescription, and the nurse observes that the unlicensed assistive personnel (UAP) has stopped turning the client from side to side as previously scheduled. What action should the nurse take?

• A. Advise the UAP to resume positioning the client on schedule
• B. Notify the healthcare provider
• C. Document the UAP's actions
• D. Discuss the situation with the client’s family

Correct answer: A

Rationale: Continuing to turn the client is crucial to prevent complications such as pressure ulcers, even if the client is less responsive. Advising the UAP to resume positioning the client on schedule is the most appropriate action in this situation. This action ensures that the client's care needs are met and helps prevent potential complications. Notifying the healthcare provider or documenting the UAP's actions may delay the necessary care for the client. Discussing the situation with the client's family is important but addressing the immediate care need of turning the client takes priority.

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