Nursing Elites

1. A nurse is reviewing the laboratory results for a client who is at 29 weeks of gestation. Which of the following results should the nurse report to the provider?

• A. WBC count 11,000/mm³
• B. Hgb 11.2 g/dL
• C. Hct 34%
• D. Platelets 140,000/mm³

Correct answer: D

Rationale: A platelet count of 140,000/mm³ is at the lower end of the normal range but can be concerning in pregnancy, especially if there are signs of thrombocytopenia or bleeding. Thrombocytopenia in pregnancy can lead to complications such as bleeding during childbirth or excessive bleeding postpartum. The other laboratory values mentioned are within normal ranges for pregnancy and do not typically raise immediate concerns. High WBC counts can be a normal response to pregnancy, hemoglobin levels around 11.2 g/dL and hematocrit levels around 34% are also considered normal in the third trimester.

2. A client with a new diagnosis of heart failure is prescribed furosemide. Which of the following instructions should the nurse include?

• A. Take the medication in the morning.
• B. Increase intake of potassium-rich foods.
• C. Report a decrease in urine output.
• D. Expect swelling in the lower extremities.

Correct answer: B

Rationale: The correct answer is to instruct the client to increase their intake of potassium-rich foods. Furosemide, a loop diuretic, can lead to potassium loss, which may cause hypokalemia. Increasing potassium intake can help prevent this electrolyte imbalance. Choice A is incorrect because furosemide is usually taken in the morning to prevent sleep disturbances due to increased urination. Choice C is incorrect because a decrease in urine output could indicate a problem and should be reported immediately. Choice D is incorrect because furosemide is used to reduce swelling in the body, including the lower extremities, so expecting swelling is not appropriate.

3. A nurse is preparing to administer 1 unit of packed RBCs to a client. Which of the following findings should cause the nurse to delay the transfusion?

• A. Blood pressure 140/90 mm Hg
• B. Urine output of 40 mL/hr
• C. Temperature 38.2°C (100.8°F)
• D. Hemoglobin 8 g/dL

Correct answer: C

Rationale: A temperature of 38.2°C (100.8°F) suggests the possibility of an underlying infection or fever, which should be evaluated before proceeding with the transfusion to prevent complications. Elevated temperature can indicate an immune response to incompatible blood components, increasing the risk of a transfusion reaction. The other vital signs and lab results provided are within acceptable ranges for administering packed RBCs, making choices A, B, and D less likely to cause a delay in the transfusion.

4. A client is receiving vancomycin. Which of the following should the nurse monitor?

• A. Blood glucose levels
• B. Serum creatinine
• C. INR levels
• D. Liver function tests

Correct answer: B

Rationale: The correct answer is B: Serum creatinine. Vancomycin is known to be nephrotoxic, meaning it can cause kidney damage. Monitoring serum creatinine levels is essential to assess kidney function and detect any signs of nephrotoxicity. Blood glucose levels (choice A) are not directly affected by vancomycin. INR levels (choice C) are typically monitored for clients on anticoagulants, not vancomycin. Liver function tests (choice D) are not primarily affected by vancomycin use; kidney function is of greater concern.

5. A nurse in a mental health facility receives a change-of-shift report on four clients. Which of the following clients should the nurse assess first?

• A. Client placed in restraints for aggressive behavior
• B. A new client with a history of a 4.5 kg weight loss in the past two months
• C. Client who received a PRN dose of haloperidol 2 hours ago for increased anxiety
• D. Client who will be receiving his first ECT treatment today

Correct answer: A

Rationale: A client in restraints due to aggressive behavior needs immediate assessment to ensure safety and well-being. The nurse should assess this client first to address any potential risks, such as circulation issues, skin integrity problems, and ongoing agitation. Choices B, C, and D do not present immediate safety concerns that require urgent assessment compared to a client restrained for aggressive behavior.

Similar Questions