Nursing Elites

1. A nurse is caring for a client who is receiving total parenteral nutrition. Which of the following laboratory findings should the nurse report to the provider?

• A. Prealbumin level of 20 mg/dL
• B. Serum albumin level of 3.5 g/dL
• C. Serum sodium level of 138 mEq/L
• D. Blood glucose level of 120 mg/dL

Correct answer: D

Rationale: The correct answer is D because a blood glucose level of 120 mg/dL falls within the normal range. A low serum albumin level, as mentioned in choice B, should be reported as it may indicate malnutrition. Choices A and C are within normal ranges and would not typically require immediate reporting.

2. A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following actions should the nurse take?

• A. Administer 0.9% sodium chloride IV
• B. Administer a hypotonic IV solution
• C. Encourage oral fluid intake
• D. Restrict oral fluid intake

Correct answer: A

Rationale: In a client with a sodium level of 125 mEq/L (hyponatremia), the nurse should administer 0.9% sodium chloride IV to help increase sodium levels. Choice B, administering a hypotonic IV solution, would further decrease the sodium level. Choice C, encouraging oral fluid intake, is contraindicated as it can dilute the sodium concentration further. Choice D, restricting oral fluid intake, could worsen the client's condition by leading to dehydration and further electrolyte imbalances.

3. What is the primary nursing intervention for a patient experiencing hypoglycemia?

• A. Administer IV fluids
• B. Check blood sugar levels
• C. Provide oral glucose
• D. Recheck blood sugar levels in 15 minutes

Correct answer: D

Rationale: The correct answer is to recheck blood sugar levels in 15 minutes. This intervention is crucial to ensure that the hypoglycemia has been effectively corrected after the initial treatment. Administering IV fluids may be necessary in cases of severe dehydration but is not the primary intervention for hypoglycemia. Checking blood sugar levels is important, but the primary intervention should focus on treating the low blood sugar levels first, which is done by providing oral glucose. However, the most critical step after providing initial treatment is to recheck blood sugar levels to confirm that they have improved to safe levels.

4. A nurse is assessing a client who has pericarditis. Which of the following findings is the priority?

• A. Paradoxical pulse
• B. Dependent edema
• C. Pericardial friction rub
• D. Substernal chest pain

Correct answer: A

Rationale: In a client with pericarditis, the priority finding is a paradoxical pulse. This is a crucial sign of cardiac tamponade, a life-threatening complication of pericarditis where fluid accumulates in the pericardial sac, causing compression of the heart. A paradoxical pulse is an exaggerated decrease in systolic blood pressure (>10 mmHg) during inspiration. Prompt recognition and intervention are essential to prevent hemodynamic instability and cardiac arrest. Dependent edema (choice B) is not typically associated with pericarditis. Pericardial friction rub (choice C) is a common finding in pericarditis but does not indicate the urgency of intervention as a paradoxical pulse. Substernal chest pain (choice D) is a classic symptom of pericarditis but is not as critical as a paradoxical pulse in the context of assessing for complications.

5. A nurse is caring for a client who has pneumonia and is receiving oxygen therapy. Which of the following findings indicates the need for suctioning?

• A. Increased respiratory rate.
• B. Oxygen saturation 96%.
• C. Clear lung sounds.
• D. Productive cough.

Correct answer: A

Rationale: The correct answer is A: Increased respiratory rate. An increased respiratory rate suggests the client is having difficulty clearing secretions and may require suctioning. Oxygen saturation of 96% is within the normal range and indicates adequate oxygenation. Clear lung sounds suggest good air entry without the need for suctioning. A productive cough, although a symptom of pneumonia, does not directly indicate the need for suctioning.

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