Nursing Elites

1. During the initial visit, which intervention is most important for the nurse to implement?

• A. Determine how the client is cared for when the caregiver is not present.
• B. Develop a client needs assessment and review it with the caregiver.
• C. Evaluate the caregiver's ability to care for the client's needs.
• D. Review with the caregiver the interventions provided each day.

Correct answer: A

Rationale: The most important intervention for the nurse to implement during the initial visit is to determine how the client is cared for when the caregiver is not present. This is crucial for ensuring continuous and adequate care, especially for a bed-bound client with multiple sclerosis who relies heavily on the caregiver. While developing a client needs assessment (choice B) and evaluating the caregiver's ability (choice C) are important, understanding the care plan in the caregiver's absence takes precedence. Reviewing daily interventions with the caregiver (choice D) is valuable but not as critical as knowing the care plan during the caregiver's absence.

2. In caring for a client receiving the aminoglycoside antibiotic gentamicin, what diagnostic test should the nurse prioritize monitoring?

• A. Urinalysis
• B. Serum creatinine
• C. Serum osmolarity
• D. Liver enzymes

Correct answer: B

Rationale: The correct answer is B: Serum creatinine. Aminoglycosides, such as gentamicin, are known to cause nephrotoxicity, which can lead to kidney damage. Monitoring serum creatinine levels is crucial in assessing renal function and detecting any potential kidney problems early. Choices A, C, and D are incorrect because urinalysis primarily assesses urine composition, serum osmolarity measures the concentration of solutes in the blood, and liver enzymes are not directly impacted by aminoglycoside antibiotics like gentamicin.

3. After checking the fingerstick glucose at 1630, what action should be implemented?

• A. Notify the healthcare provider.
• B. Administer 8 units of insulin aspart SubQ.
• C. Give an IV bolus of Dextrose 50% 50 ml.
• D. Perform quality control on the glucometer.

Correct answer: B

Rationale: Administering insulin aspart (rapid-acting insulin) is the appropriate action to manage the elevated glucose level of 1630. Choice A, notifying the healthcare provider, is not the immediate action needed for this glucose level. Choice C, giving an IV bolus of Dextrose 50%, would exacerbate hyperglycemia instead of treating it. Choice D, performing quality control on the glucometer, is not relevant to the management of the patient's glucose level at this time.

4. A client with a history of chronic kidney disease (CKD) is receiving erythropoietin therapy. Which assessment finding is most concerning?

• A. Increased fatigue
• B. Headache
• C. Elevated blood pressure
• D. Low urine output

Correct answer: C

Rationale: In a client with chronic kidney disease receiving erythropoietin therapy, elevated blood pressure is the most concerning assessment finding. Erythropoietin can increase red blood cell production, leading to thicker blood, which in turn can elevate blood pressure. Elevated blood pressure in this scenario may indicate worsening hypertension, which requires prompt intervention to prevent complications such as stroke, heart attack, or further kidney damage. Increased fatigue (choice A) is a common symptom in CKD patients and can be expected with erythropoietin therapy. Headache (choice B) can occur but is less concerning than elevated blood pressure in this context. Low urine output (choice D) is a significant finding in CKD, but in a client receiving erythropoietin, elevated blood pressure takes precedence due to its potential for immediate adverse effects.

5. A client with rapid respirations and audible rhonchi is admitted to the intensive care unit because of a pulmonary embolism (PE). Low-flow oxygen by nasal cannula and weight-based heparin protocol are initiated. Which intervention is most important for the nurse to include in this client's plan of care?

• A. Evaluate blood clotting factors daily.
• B. Encourage incentive spirometry use.
• C. Administer pain medication as needed.
• D. Monitor for signs of bleeding.

Correct answer: A

Rationale: Evaluating blood clotting factors daily is crucial when a client is on heparin therapy to monitor for potential complications such as bleeding or clotting issues. This monitoring helps ensure that the heparin dose is within the therapeutic range and reduces the risk of bleeding or clotting complications. Encouraging incentive spirometry use is beneficial for preventing atelectasis and improving lung function, but in this scenario, monitoring blood clotting factors takes precedence. Administering pain medication as needed is important for the client's comfort but is not the priority in managing a pulmonary embolism. Monitoring for signs of bleeding is important due to heparin therapy, but evaluating blood clotting factors provides more specific information on the client's response to treatment.

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