Nursing Elites

1. A healthcare professional is reviewing the laboratory report of a client who is receiving filgrastim. Which of the following laboratory values should the healthcare professional monitor to determine the effectiveness of the treatment?

• A. WBC count.
• B. Serum potassium.
• C. Hemoglobin level.
• D. Serum creatinine.

Correct answer: A

Rationale: Filgrastim works by stimulating the production of white blood cells. Therefore, monitoring the white blood cell (WBC) count is essential to assess the effectiveness of the treatment. Choice B, serum potassium, is not directly affected by filgrastim therapy. Choice C, hemoglobin level, is important but not the primary indicator of filgrastim's effectiveness. Choice D, serum creatinine, is unrelated to the action of filgrastim and would not reflect its effectiveness.

2. A client with chronic kidney disease needs dietary restrictions. What restriction is necessary?

• A. Increase protein intake
• B. Limit potassium-rich foods
• C. Increase fluid intake to prevent dehydration
• D. Increase phosphorus intake

Correct answer: B

Rationale: The correct answer is to limit potassium-rich foods for clients with chronic kidney disease. Excessive potassium can be harmful to individuals with compromised kidney function, leading to complications. This restriction helps in managing the condition and preventing further health issues. Choice A is incorrect because increasing protein intake can put additional stress on the kidneys. Choice C is incorrect as excessive fluid intake can burden the kidneys. Choice D is incorrect as increasing phosphorus intake can be harmful for individuals with kidney disease.

3. A nurse on an acute unit has received a change of shift report for 4 clients. Which of the following clients should the nurse assess first?

• A. A client who is 1 hr postoperative and has hypoactive bowel sounds.
• B. A client who has a fractured left tibia and pallor in the affected extremity.
• C. A client who had a cardiac catheterization 3 hr ago and has 3+ pedal pulses.
• D. A client who has an elevated AST level following the administration of azithromycin.

Correct answer: B

Rationale: The correct answer is B because pallor in an extremity after a fracture could indicate compromised circulation, making it a priority for assessment. Choice A is not the priority as hypoactive bowel sounds in a client 1 hr postoperative, while concerning, do not indicate a life-threatening condition. Choice C, a client who had a cardiac catheterization 3 hr ago and has 3+ pedal pulses, indicates good perfusion and does not require immediate attention. Choice D, a client with an elevated AST level following the administration of azithromycin, may require further assessment but is not as urgent as the client with potential compromised circulation in choice B.

4. How should a healthcare professional assess a patient with suspected sepsis?

• A. Monitor vital signs and administer antibiotics
• B. Monitor for signs of infection and confusion
• C. Monitor for fever and check oxygen saturation
• D. Assess for confusion and administer fluids

Correct answer: A

Rationale: When assessing a patient with suspected sepsis, it is crucial to monitor vital signs like temperature, heart rate, respiratory rate, and blood pressure. Administering antibiotics promptly is also vital to treat the infection causing sepsis. This approach helps in preventing the progression of sepsis to severe stages and reduces the risk of complications. Choice B is incorrect because only monitoring signs of infection and confusion may delay necessary treatment with antibiotics. Choice C is incorrect as it focuses only on fever and oxygen saturation, missing other important vital signs. Choice D is incorrect because assessing for confusion alone is not sufficient, and administering fluids should be guided by the patient's fluid status rather than being an initial step in suspected sepsis assessment.

5. A client with a chest tube is post-op. What is the priority nursing action?

• A. Clamp the chest tube every 2 hours
• B. Check for air leaks and proper functioning of the chest tube
• C. Encourage deep breathing and coughing every 2 hours
• D. Encourage frequent coughing to clear secretions

Correct answer: B

Rationale: The correct answer is to check for air leaks and ensure the proper functioning of the chest tube. This action is crucial post-op to prevent complications such as pneumothorax or hemothorax. Clamping the chest tube every 2 hours (Choice A) is incorrect as it can lead to a buildup of pressure within the chest, risking complications. Encouraging deep breathing and coughing every 2 hours (Choice C) is important for respiratory hygiene but not the priority over ensuring the chest tube's proper function. Encouraging frequent coughing to clear secretions (Choice D) is not the priority when assessing a chest tube post-op; ensuring the chest tube's integrity and function take precedence.

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