Nursing Elites

1. In a client with liver cirrhosis admitted with ascites and 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 elevated ammonia level of 80 mcg/dl is most concerning in a client with liver cirrhosis because it may indicate hepatic encephalopathy, a serious complication. Serum albumin, though low, is expected in cirrhosis and contributes to ascites. Bilirubin elevation is common in liver disease but may not be the most concerning in this case. Prothrombin time is typically prolonged in liver disease but may not be as acute as an elevated ammonia level suggesting hepatic encephalopathy.

2. A male client reports the onset of numbness and tingling in his fingers and around his mouth. Which lab test is important for the nurse to review before contacting the healthcare provider?

• A. Capillary glucose
• B. Urine specific gravity
• C. Serum calcium
• D. White blood cell count

Correct answer: C

Rationale: The correct answer is C: Serum calcium. Numbness and tingling in the fingers and around the mouth are indicative of hypocalcemia. Serum calcium levels should be reviewed as they play a crucial role in diagnosing and managing hypocalcemia. Option A, capillary glucose, is not relevant to the symptoms described. Option B, urine specific gravity, is not typically used to assess numbness and tingling. Option D, white blood cell count, is unrelated to the symptoms presented by the client.

3. A client is being treated with an aminoglycoside antibiotic for a serious gram-negative infection. What nursing action should be included in the plan of care to prevent nephrotoxicity?

• A. Monitor serum creatinine levels daily.
• B. Administer the antibiotic over a longer period of time.
• C. Encourage increased fluid intake.
• D. Restrict dietary protein intake.

Correct answer: A

Rationale: Monitoring serum creatinine levels daily is the essential nursing action to prevent nephrotoxicity from aminoglycoside antibiotics. Aminoglycosides can cause kidney damage, so monitoring serum creatinine levels helps in detecting early signs of nephrotoxicity. Administering the antibiotic over a longer period of time (choice B) does not directly prevent nephrotoxicity. Encouraging increased fluid intake (choice C) is a general good practice but not specifically aimed at preventing nephrotoxicity. Restricting dietary protein intake (choice D) is not a direct preventive measure against aminoglycoside-induced nephrotoxicity.

4. The nurse and an unlicensed assistive personnel (UAP) are providing care for a client with a nasogastric tube (NGT) when the client begins to vomit. How should the nurse manage this situation?

• A. Direct the UAP to measure the emesis while the nurse irrigates the NGT
• B. Stop the NGT feed and notify the healthcare provider
• C. Increase the NGT suction pressure
• D. Elevate the head of the bed

Correct answer: A

Rationale: During vomiting in a client with an NGT, it is essential for the nurse to direct the UAP to measure the emesis to monitor the output. This helps in assessing the client's condition and response to treatment. Meanwhile, irrigating the NGT can be beneficial to relieve any obstruction that might be contributing to the vomiting. Stopping the NGT feed and notifying the healthcare provider (choice B) is important but not the immediate action needed. Increasing the NGT suction pressure (choice C) is unnecessary and can lead to complications. Elevating the head of the bed (choice D) is a general intervention to prevent aspiration but may not address the immediate issue of managing the vomiting episode and potential tube obstruction.

5. A female client reports she has not had a bowel movement for 3 days, but now is defecating frequent small amounts of liquid stool. Which action should the nurse implement?

• A. Digitally check the client for a fecal impaction
• B. Administer a laxative to stimulate bowel movement
• C. Increase fluid intake to soften stool
• D. Perform a digital rectal examination

Correct answer: A

Rationale: The correct action for the nurse to implement is to digitally check the client for a fecal impaction. In this scenario, the client's presentation of frequent small amounts of liquid stool after a period of no bowel movement suggests a possible impaction. By performing a digital examination, the nurse can assess for the presence of a blockage that may be causing the symptoms. Administering a laxative (Choice B) without assessing for impaction can worsen the situation. Increasing fluid intake (Choice C) is generally beneficial for bowel health but may not address the immediate issue of a potential impaction. Performing a digital rectal examination (Choice D) is similar to Choice A but is more focused on assessing the rectum itself rather than checking for an impaction.

Similar Questions