Nursing Elites

1. A client with cirrhosis is admitted with jaundice, fatigue, and a distended abdomen. Which laboratory result is most important for the nurse to monitor?

• A. Ammonia level
• B. White blood cell count
• C. Albumin level
• D. Hemoglobin level

Correct answer: A

Rationale: Corrected Rationale: In clients with cirrhosis, elevated ammonia levels can lead to hepatic encephalopathy, which is a serious complication. Monitoring ammonia levels is crucial to assess for changes in mental status and initiate treatment if needed. White blood cell count (choice B) is not the most important parameter to monitor in this scenario as it does not directly relate to the complications of cirrhosis. Albumin level (choice C) and hemoglobin level (choice D) are also important in cirrhosis, but in this case, monitoring ammonia level takes precedence due to its direct association with hepatic encephalopathy.

2. A client with cirrhosis is admitted with ascites and peripheral edema. Which intervention should the nurse implement first?

• A. Elevate the legs to reduce swelling.
• B. Restrict fluids to reduce fluid overload.
• C. Administer furosemide to reduce fluid overload.
• D. Monitor the client's intake and output.

Correct answer: C

Rationale: Administering a diuretic like furosemide is the priority intervention for a client with cirrhosis, ascites, and peripheral edema. Furosemide helps reduce fluid overload by promoting diuresis. Elevating the legs may provide some symptomatic relief but does not address the underlying issue of fluid overload. Restricting fluids is not appropriate initially as the client needs proper hydration while managing fluid balance. Monitoring intake and output is important but not the first action to address the immediate fluid overload in this client.

3. A client with a fractured femur is placed in skeletal traction. What action should the nurse prioritize?

• A. Ensure that the weights are freely hanging.
• B. Place pillows under the client's knees.
• C. Adjust the weights to alleviate discomfort.
• D. Ensure that the traction ropes are free of knots.

Correct answer: A

Rationale: The correct action the nurse should prioritize when a client is placed in skeletal traction for a fractured femur is to ensure that the weights are freely hanging. This is crucial to maintain proper alignment of the bone and prevent complications. Placing pillows under the client's knees (Choice B) is not a priority in skeletal traction. Adjusting the weights to alleviate discomfort (Choice C) should not be done without proper orders from the healthcare provider. Ensuring that the traction ropes are free of knots (Choice D) is important but ensuring the weights hang freely is the priority to maintain traction effectiveness.

4. A client with anemia is prescribed iron supplements. What teaching should the nurse provide?

• A. Take iron supplements with meals to prevent stomach upset.
• B. Take iron supplements with milk to improve absorption.
• C. Expect black, tarry stools as a side effect of iron supplements.
• D. Take iron supplements with vitamin C to improve absorption.

Correct answer: D

Rationale: The correct answer is D: Take iron supplements with vitamin C to improve absorption. Vitamin C enhances iron uptake, making it more bioavailable for the body. It is essential to avoid taking iron supplements with milk (choice B) as calcium-rich foods can hinder iron absorption. Taking iron supplements with meals (choice A) can help reduce stomach upset, but the optimal way to enhance absorption is with vitamin C. Black, tarry stools (choice C) are not a typical side effect of iron supplements and should be reported to the healthcare provider.

5. Prior to administering warfarin to a client with a history of atrial fibrillation, what lab result should the nurse review?

• A. White blood cell count.
• B. Prothrombin time (PT) and International Normalized Ratio (INR).
• C. Hemoglobin and hematocrit.
• D. Blood urea nitrogen (BUN) and creatinine.

Correct answer: B

Rationale: The correct answer is B: Prothrombin time (PT) and International Normalized Ratio (INR). These lab values are crucial for monitoring the effectiveness of warfarin, an anticoagulant medication. PT measures the time it takes for blood to clot, while INR standardizes these results. Ensuring the client's PT/INR levels are within the therapeutic range is essential to prevent clotting or excessive bleeding. Choices A, C, and D are incorrect as they are not directly related to monitoring warfarin therapy in a client with atrial fibrillation.

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