Nursing Elites

1. A client with liver dysfunction has low serum levels of thrombin. The nurse provides care, anticipating that this client is most at risk of

• A. Dehydration
• B. Malnutrition
• C. Bleeding
• D. Infection

Correct answer: C

Rationale: Thrombin is produced by the liver and is necessary for normal clotting. When a client with liver dysfunction has low serum levels of thrombin, they are at risk of bleeding due to impaired clotting mechanisms. Dehydration (choice A) is not directly related to low thrombin levels. Malnutrition (choice B) may impact overall health but is not the most immediate concern associated with low thrombin levels. Infection (choice D) is not directly related to the clotting function affected by low thrombin levels.

2. You promote hemodynamic stability in a patient with upper GI bleeding by:

• A. Encouraging oral fluid intake.
• B. Monitoring central venous pressure.
• C. Monitoring laboratory test results and vital signs.
• D. Giving blood, electrolyte and fluid replacement.

Correct answer: D

Rationale: Promoting hemodynamic stability in a patient with upper GI bleeding involves giving blood, electrolyte, and fluid replacement.

3. The nurse assesses the client's understanding of the relationship between body position and gastroesophageal reflux. Which response would indicate that the client understands measures to avoid problems with reflux while sleeping?

• A. I can elevate the foot of the bed 4 to 6 inches.
• B. I can sleep on my stomach with my head turned to the left.
• C. I can sleep on my back without a pillow under my head.
• D. I can elevate the head of the bed 4 to 6 inches.

Correct answer: D

Rationale: Sleeping with the head of the bed elevated encourages movement of food through the esophagus by gravity. By fostering esophageal acid clearance, gravity helps keep the acidic pepsin and alkaline biliary secretions from contacting the esophagus. Elevating the foot of the bed does not affect clearance of esophageal acid. Sleeping on the stomach with the head turned to the left will not decrease reflux incidence. Sleeping flat without a pillow under the head does not enhance clearance.

4. Leigh Ann is receiving pancrelipase (Viokase) for chronic pancreatitis. Which observation best indicates the treatment is effective?

• A. There is no skin breakdown.
• B. Her appetite improves.
• C. She loses more than 10 lbs.
• D. Stools are less fatty and decreased in frequency.

Correct answer: D

Rationale: The effectiveness of pancrelipase (Viokase) for chronic pancreatitis is best indicated by stools being less fatty and decreased in frequency.

5. Elmer is scheduled for a proctoscopy and has an I.V. The doctor wrote an order for 5mg of I.V. diazepam(Valium). Which order is correct regarding diazepam?

• A. Give diazepam in the I.V. port closest to the vein.
• B. Mix diazepam with 50 ml of dextrose 5% in water and give over 15 minutes.
• C. Give diazepam rapidly I.V. to prevent the bloodstream from diluting the drug mixture.
• D. Question the order because I.V. administration of diazepam is contraindicated.

Correct answer: A

Rationale: The correct method for administering I.V. diazepam is to give it in the I.V. port closest to the vein.

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