Nursing Elites

1. A healthcare provider is assessing a client with a history of hypertension who is currently taking a diuretic. Which assessment finding is most important to report to the healthcare provider?

• A. Potassium level of 3.2 mEq/L
• B. Blood pressure of 148/90 mmHg
• C. Pulse rate of 62 beats per minute
• D. Blood glucose level of 130 mg/dl

Correct answer: A

Rationale: A potassium level of 3.2 mEq/L is low and places the client at risk for cardiac arrhythmias, requiring immediate intervention. Hypokalemia can result from diuretic use and can lead to serious complications such as irregular heart rhythms. Monitoring and correcting potassium levels are crucial in preventing adverse cardiac events. The other options, though important, do not pose an immediate life-threatening risk compared to the low potassium level.

2. The nurse is assessing a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which assessment finding requires immediate intervention?

• A. Elevated blood pressure
• B. Increased fatigue
• C. Headache
• D. Elevated hemoglobin

Correct answer: A

Rationale: The correct answer is A: Elevated blood pressure. In a client with chronic kidney disease (CKD) receiving erythropoietin therapy, elevated blood pressure requires immediate intervention. This finding is concerning as it may indicate worsening hypertension, which can lead to further complications. Increased fatigue (choice B) is common in CKD but may not require immediate intervention unless severe. Headache (choice C) can be a symptom to monitor but does not pose an immediate threat like elevated blood pressure. Elevated hemoglobin (choice D) is actually a desired outcome of erythropoietin therapy and does not require immediate intervention.

3. A client with chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation. Which laboratory value is most concerning?

• A. Serum potassium of 6.5 mEq/L
• B. Serum bicarbonate of 18 mEq/L
• C. Serum glucose of 350 mg/dl
• D. Serum sodium of 135 mEq/L

Correct answer: A

Rationale: A serum potassium level of 6.5 mEq/L is concerning in a client with COPD exacerbation as it may lead to life-threatening arrhythmias, requiring immediate intervention. Hyperkalemia can cause cardiac arrhythmias, which pose a significant risk to the patient's life. Options B, C, and D are not typically associated with immediate life-threatening risks in the context of a COPD exacerbation.

4. An adolescent's mother calls the clinic because the teen is having recurrent vomiting and has become combative in the last 2 days. The mother states that the teen takes vitamins, calcium, magnesium, and aspirin. Which nursing intervention has the highest priority?

• A. Advise the mother to withhold all medications by mouth.
• B. Instruct the mother to take the teen to the emergency room.
• C. Recommend that the teen withhold food and fluids for 2 hours.
• D. Suggest that the adolescent breathe slowly and deeply.

Correct answer: B

Rationale: The correct answer is to instruct the mother to take the teen to the emergency room. The symptoms described, including recurrent vomiting and becoming combative after taking vitamins, calcium, magnesium, and aspirin, indicate a potential overdose or a serious condition. Therefore, immediate medical evaluation in the emergency room is crucial. Advising to withhold all medications by mouth (Choice A) may delay necessary treatment. Recommending to withhold food and fluids (Choice C) is not appropriate in this urgent situation. Suggesting deep breathing (Choice D) does not address the seriousness of the symptoms and the need for immediate medical attention.

5. A female client with ovarian cancer is receiving chemotherapy. Which laboratory result should the nurse report to the healthcare provider immediately?

• A. White blood cell count of 2,000/mm³
• B. Platelet count of 100,000/mm³
• C. Hemoglobin level of 10 g/dL
• D. Serum creatinine level of 1.5 mg/dL

Correct answer: A

Rationale: A white blood cell count of 2,000/mm³ is critically low and places the client at high risk for infection, requiring immediate intervention. Neutropenia, a low white blood cell count, is a common side effect of chemotherapy. A decreased white blood cell count compromises the immune system's ability to fight infections, making it a priority to address to prevent serious complications. Platelet count of 100,000/mm³ is relatively low but not as urgent as a severely low white blood cell count. Hemoglobin level of 10 g/dL is within the normal range for females and does not require immediate intervention. Serum creatinine level of 1.5 mg/dL is also within the normal range and does not pose an immediate threat to the client's health.

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