Nursing Elites

1. A client with end-stage renal disease (ESRD) is scheduled for hemodialysis. Which laboratory value should the nurse report to the healthcare provider immediately?

• A. Serum potassium of 5.5 mEq/L
• B. Serum calcium of 8 mg/dL
• C. Serum creatinine of 2.0 mg/dL
• D. White blood cell count of 10,000/mm³

Correct answer: A

Rationale: A serum potassium level of 5.5 mEq/L is concerning in a client with ESRD scheduled for hemodialysis as it indicates hyperkalemia, requiring immediate intervention. Hyperkalemia can lead to serious cardiac arrhythmias, especially during hemodialysis. Serum calcium, serum creatinine, and white blood cell count, while important, do not pose immediate life-threatening risks like hyperkalemia.

2. A client with cirrhosis is admitted with hepatic encephalopathy. Which laboratory value requires immediate intervention?

• A. Serum ammonia level of 80 mcg/dl
• B. Bilirubin level of 3.0 mg/dl
• C. Serum sodium level of 135 mEq/L
• D. Prothrombin time of 18 seconds

Correct answer: D

Rationale: The correct answer is D. A prothrombin time of 18 seconds is most concerning in a client with hepatic encephalopathy as it indicates impaired liver function and an increased risk of bleeding. This requires immediate intervention to prevent bleeding complications. Choice A, serum ammonia level of 80 mcg/dl, is elevated but not as urgent as the abnormal prothrombin time. Choice B, bilirubin level of 3.0 mg/dl, is elevated but does not directly indicate an urgent need for intervention in this situation. Choice C, serum sodium level of 135 mEq/L, is within the normal range and does not require immediate intervention.

3. A confused, older client with Alzheimer's disease becomes incontinent of urine when attempting to find the bathroom. Which action should the nurse implement?

• A. Assist the client to a bedside commode every two hours
• B. Insert an indwelling catheter
• C. Use adult diapers to manage incontinence
• D. Restrict fluids in the evening

Correct answer: A

Rationale: The correct action for the nurse to implement is to assist the client to a bedside commode every two hours. This approach, known as scheduled toileting, is essential in managing incontinence in clients with cognitive impairments like Alzheimer's disease. By providing regular assistance to the client to use the commode, the nurse can help maintain continence and reduce accidents. Inserting an indwelling catheter (Choice B) should be avoided if possible to prevent the risk of urinary tract infections. Using adult diapers (Choice C) should be considered a last resort and not the initial intervention. Restricting fluids in the evening (Choice D) is not appropriate as it may lead to dehydration and other complications.

4. In caring for a client with a PCA infusion of morphine sulfate through the right cephalic vein, the nurse assesses that the client is lethargic with a blood pressure of 90/60, pulse rate of 118 beats per minute, and respiratory rate of 8 breaths per minute. What assessment should the nurse perform next?

• A. Note the appearance and patency of the client's peripheral IV site.
• B. Palpate the volume of the client's right radial pulse.
• C. Auscultate the client's breath sounds bilaterally.
• D. Observe the amount and dose of morphine in the PCA pump syringe.

Correct answer: D

Rationale: In this scenario, the nurse is dealing with a lethargic client with concerning vital signs after a PCA infusion of morphine sulfate. The next assessment the nurse should perform is to observe the amount and dose of morphine in the PCA pump syringe. This is crucial to evaluate for possible overdose, as the client's symptoms could be indicative of opioid toxicity. Checking the morphine amount and dose will help the nurse adjust the treatment accordingly. Choices A, B, and C do not directly address the potential cause of the client's lethargy and abnormal vital signs related to the morphine infusion.

5. The nurse is preparing to administer an intramuscular injection to a client with muscle wasting in the gluteal region. What is the most appropriate site for the injection?

• A. Dorsogluteal site
• B. Ventrogluteal site
• C. Deltoid site
• D. Vastus lateralis site

Correct answer: D

Rationale: The vastus lateralis site is the most appropriate for an IM injection in a client with muscle wasting in the gluteal region. Administering the injection in the vastus lateralis ensures effective medication delivery due to muscle wasting in the gluteal region, preventing potential complications associated with the dorsogluteal or ventrogluteal sites, which may not be suitable in this specific client case. The deltoid site is mainly used for smaller volumes of medication and may not be ideal for this scenario.

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