Nursing Elites

1. A nurse is caring for a client who has cirrhosis. Which of the following laboratory values should the nurse expect to be decreased?

• A. Bilirubin.
• B. Albumin.
• C. Ammonia.
• D. Prothrombin time.

Correct answer: B

Rationale: In clients with cirrhosis, albumin levels are typically decreased due to impaired liver function. Bilirubin levels are often increased in cirrhosis due to the liver's inability to process bilirubin efficiently. Ammonia levels may be elevated in cirrhosis due to impaired ammonia metabolism by the liver. Prothrombin time is usually prolonged in cirrhosis because the liver's ability to synthesize clotting factors is impaired.

2. What is the priority intervention for a patient presenting with chest pain?

• A. Administer aspirin
• B. Administer nitroglycerin
• C. Reposition the patient
• D. Prepare for surgery

Correct answer: A

Rationale: The correct answer is to administer aspirin. Administering aspirin is a priority intervention for a patient presenting with chest pain because it helps reduce the risk of further clot formation and improves oxygenation. Aspirin is commonly used in the initial management of suspected cardiac chest pain. Administering nitroglycerin can follow aspirin administration to help with vasodilation. Repositioning the patient or preparing for surgery are not the primary interventions for chest pain presentation.

3. A nurse is assessing a client who has increased intracranial pressure (ICP). Which of the following findings should the nurse expect?

• A. Bradycardia.
• B. Increased level of consciousness.
• C. Tachycardia.
• D. Hyperactive bowel sounds.

Correct answer: C

Rationale: The correct answer is C: Tachycardia. In a client with increased intracranial pressure (ICP), tachycardia is a common finding. This is due to the body's compensatory mechanisms in response to the increased pressure. Bradycardia (choice A) is not typically associated with increased ICP and may indicate a different issue. Increased level of consciousness (choice B) is unlikely with increased ICP, as it often leads to altered mental status. Hyperactive bowel sounds (choice D) are not directly related to increased ICP and are more indicative of gastrointestinal issues.

4. A nurse is preparing to measure the temperature of an infant. Which of the following actions should the nurse take?

• A. Place the tip of the thermometer under the center of the infant's axilla.
• B. Pull the pinna of the infant's ear forward before inserting the probe.
• C. Insert the probe 3.8 cm (1.5 inches) into the infant's rectum.
• D. Insert the thermometer in front of the infant's tongue.

Correct answer: A

Rationale: The correct method for measuring an infant's temperature is by placing the tip of the thermometer under the center of the infant's axilla (armpit). This method is non-invasive and safe. Pulling the pinna of the ear forward is used when taking a tympanic temperature. Inserting the probe into the rectum is done for rectal temperature measurement, which is not recommended as an initial method in infants. Inserting the thermometer in front of the infant's tongue is not a standard method for measuring temperature in infants.

5. A healthcare provider is teaching a client who has a new diagnosis of hypertension about dietary management. Which of the following foods should the healthcare provider recommend?

• A. Carrots
• B. Whole grains
• C. Lean beef
• D. Bananas

Correct answer: C

Rationale: The correct answer is 'Lean beef.' Lean beef is a good source of protein, which is essential for a balanced diet. While carrots and bananas are healthy food choices, they are not specifically recommended for clients with hypertension. Whole grains are a better alternative to refined grains for individuals with hypertension, but lean beef is a more suitable recommendation due to its protein content.

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