Nursing Elites

1. A male client with HIV on antiretroviral therapy complains of constant hunger and thirst while losing weight. What action should the nurse implement?

• A. Check the client's glucose level with a glucometer.
• B. Measure the client's weight accurately.
• C. Reassure the client that weight will stabilize as viral load decreases.
• D. Increase the dose of saquinavir.

Correct answer: A

Rationale: The correct action for the nurse to implement is to check the client's glucose level with a glucometer. Constant hunger and thirst along with weight loss can be indicative of hyperglycemia, a possible side effect of saquinavir. Monitoring the client's glucose levels is crucial in this situation. Measuring the client's weight accurately (Choice B) is important for monitoring purposes but does not address the immediate concern of hunger, thirst, and weight loss. Reassuring the client that weight will stabilize as viral load decreases (Choice C) is not appropriate in this scenario as the symptoms described need immediate attention. Increasing the dose of saquinavir (Choice D) without assessing the client's glucose level can worsen the hyperglycemia.

2. A nurse from the maternity unit is floated to the critical care unit because of staff shortage on the evening shift. Which client would be appropriate to assign to this nurse?

• A. A client with a Dopamine drip IV with vital signs monitored every 5 minutes
• B. A client with a myocardial infarction that is free from pain and dysrhythmias
• C. A client with a tracheotomy of 24 hours in some respiratory distress
• D. A client with a pacemaker inserted this morning with intermittent capture

Correct answer: B

Rationale: In this scenario, it is more appropriate to assign a stable client, such as the one with a myocardial infarction who is free from pain and dysrhythmias, to a nurse who lacks specialized critical care experience. This client's condition is relatively stable and does not require immediate critical interventions. Choices A, C, and D involve clients with more complex and critical conditions that would be better managed by a nurse with specialized critical care training. Choice A involves a client on a Dopamine drip with frequent vital sign monitoring, Choice C has a client with a tracheotomy in respiratory distress, and Choice D describes a client with a pacemaker experiencing intermittent capture, all of which require a higher level of critical care expertise.

3. The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250, and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern?

• A. Diminished bowel sounds
• B. Loss of appetite
• C. A cold, pale lower leg
• D. Tachypnea

Correct answer: C

Rationale: A cold, pale lower leg is cause for the most concern as it could indicate compromised blood circulation, potentially leading to serious complications like ischemia or thrombosis. Diminished bowel sounds, loss of appetite, and tachypnea are not directly related to the client's condition in atrial fibrillation and the heart rate discrepancy.

4. Which of these findings should the nurse report immediately after a client has a liver biopsy?

• A. Temperature of 99.5 degrees F (37.5 degrees C)
• B. Blood pressure of 108/70
• C. Pulse oximetry reading of 96%
• D. Severe abdominal pain

Correct answer: D

Rationale: The correct answer is D, severe abdominal pain. After a liver biopsy, severe abdominal pain is a critical finding that requires immediate reporting as it may indicate internal bleeding or damage to the liver. The other vital signs provided in choices A, B, and C are within normal limits and may not be directly related to complications post liver biopsy. Therefore, the priority is to address the severe abdominal pain promptly to prevent any further complications.

5. The nurse is assessing a client with a new diagnosis of hyperthyroidism. Which assessment finding should the nurse expect?

• A. Decreased heart rate
• B. Increased appetite
• C. Cold intolerance
• D. Weight gain

Correct answer: B

Rationale: In hyperthyroidism, there is an increase in metabolism, leading to symptoms such as increased appetite, weight loss, and heat intolerance. Therefore, the nurse should expect an increased appetite in a client with hyperthyroidism. Choices A, C, and D are incorrect because decreased heart rate and cold intolerance are more commonly associated with hypothyroidism, while weight gain is not typically seen in hyperthyroidism.

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