Nursing Elites

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

• 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 cognitive impairment, altered mental status, and even coma. Serum albumin, bilirubin, and prothrombin time are also important markers in liver cirrhosis but are not as directly associated with the risk of hepatic encephalopathy as elevated ammonia levels.

2. A male client is having abdominal pain after a left femoral angioplasty and stent, and is asking for additional pain medication for right lower quadrant pain (9/10). Two hours ago, he received hydrocodone/acetaminophen 7.5/7.50 mg. His vital signs are elevated from the previous hour: temperature 97.8 F, heart rate 102 beats per minute, respiration 20 breaths per minute. His abdomen is swollen, the groin access site is tender, peripheral pulses are present, but the left leg is larger than the right. Preoperatively, clopidogrel was prescribed for a history of previous peripheral stents. Another nurse is holding manual pressure on the femoral arterial access site which may be leaking into the abdomen. What data is needed to make this report complete?

• A. Client's lungs are clear bilaterally, and oxygen saturation is 97%.
• B. The surgeon needs to see the client immediately to evaluate the situation.
• C. Left peripheral pulses were present only by Doppler pre-procedure.
• D. Client's history includes multiple back surgeries and chronic pain.

Correct answer: B

Rationale: The correct answer is B. Immediate evaluation by the surgeon is necessary due to the possibility of an internal hemorrhage, which is a life-threatening condition. Choice A is incorrect as lung status and oxygen saturation are not the priority in this situation. Choice C is not relevant to the current urgent issue. Choice D, while providing additional history, is not pertinent to the immediate concern of a potential internal hemorrhage post angioplasty and stent placement.

3. The nurse is caring for a client with a tracheostomy who has thick, tenacious secretions. Which assessment finding requires immediate intervention?

• A. Crepitus around the tracheostomy site
• B. Dry and cracked tracheostomy site
• C. Mucous plugging of the tracheostomy tube
• D. Yellowing of the skin around the tracheostomy site

Correct answer: C

Rationale: Mucous plugging of the tracheostomy tube is the most concerning assessment finding in a client with a tracheostomy. It can lead to airway obstruction, which requires immediate intervention to ensure the client's airway remains patent. Crepitus around the tracheostomy site may indicate subcutaneous emphysema but is not as urgent as a blocked airway. A dry and cracked tracheostomy site may indicate poor skin integrity but does not pose an immediate threat to the client's airway. Yellowing of the skin around the tracheostomy site could suggest a localized infection, but it is not as critical as a potential airway obstruction caused by mucous plugging.

4. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which intervention should the nurse implement first?

• A. Elevate the head of the bed.
• B. Administer oxygen therapy as prescribed.
• C. Assess the client's oxygen saturation.
• D. Obtain an arterial blood gas (ABG) sample.

Correct answer: C

Rationale: Assessing the client's oxygen saturation is the first priority in managing a client with COPD receiving supplemental oxygen to ensure adequate oxygenation. Monitoring oxygen saturation levels helps in determining the effectiveness of the oxygen therapy and if adjustments are needed. Elevating the head of the bed can help with breathing but is not the first priority. Administering oxygen therapy as prescribed is important, but assessing the current oxygen saturation comes before administering more oxygen. Obtaining an arterial blood gas (ABG) sample may provide valuable information, but it is not the initial intervention needed in this situation.

5. A client is admitted for type 2 diabetes mellitus (DM) and chronic kidney disease (CKD). Which breakfast selection by the client indicates effective learning?

• A. Scrambled eggs, bacon, one slice of whole wheat toast with butter and jam.
• B. Oatmeal with butter, artificial sweetener, and strawberries, and 6 ounces of coffee.
• C. Banana pancake with maple syrup, sausage links, half grapefruit, and low-fat milk.
• D. Orange juice, yogurt with berries, cold cereal with milk, bran muffin with margarine.

Correct answer: B

Rationale: The correct answer is B. Oatmeal with butter, artificial sweetener, and strawberries is a suitable choice for a client with type 2 diabetes mellitus and chronic kidney disease as it provides a balanced meal that helps manage blood sugar levels and kidney function. Choice A contains high saturated fats and added sugars from bacon, butter, and jam, which are not ideal for this client. Choice C includes high sugar content from maple syrup and pancake, which can negatively impact blood sugar levels. Choice D contains high sugar content from orange juice and cold cereal, which can lead to blood sugar spikes, not suitable for a client with diabetes and CKD.

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