Nursing Elites

1. A nurse is reviewing the laboratory results of a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse report to the provider?

• A. White blood cell count 6,000/mm3
• B. Positive antinuclear antibody (ANA) titer
• C. Platelet count 220,000/mm3
• D. Blood urea nitrogen (BUN) 15 mg/dL

Correct answer: B

Rationale: A positive antinuclear antibody (ANA) titer is a significant finding in clients with systemic lupus erythematosus (SLE) as it indicates active disease. This result should be reported to the provider for further evaluation and management. Choices A, C, and D are within normal ranges and not specifically indicative of disease activity in SLE. Therefore, they do not require immediate reporting to the provider.

2. What is the appropriate nursing action for a patient experiencing an acute allergic reaction?

• A. Administer antihistamines
• B. Administer corticosteroids
• C. Administer oxygen
• D. Administer bronchodilators

Correct answer: A

Rationale: The appropriate nursing action for a patient experiencing an acute allergic reaction is to administer antihistamines. Antihistamines work by blocking the action of histamine, a chemical released during an allergic reaction, and can help relieve symptoms such as itching, swelling, and hives. Corticosteroids are used for severe allergic reactions not responding to antihistamines, as they have anti-inflammatory properties. Oxygen is administered in cases of respiratory distress, while bronchodilators are used for bronchospasms. However, the first-line intervention for an acute allergic reaction is antihistamines.

3. A nurse is caring for a client who is receiving TPN. Which of the following actions should the nurse take to prevent infection?

• A. Change the TPN tubing every 72 hours.
• B. Monitor the client's blood glucose every 4 hours.
• C. Monitor the client's urine output every 8 hours.
• D. Use sterile technique when changing the central line dressing.

Correct answer: D

Rationale: The correct answer is D: 'Use sterile technique when changing the central line dressing.' When caring for a client receiving TPN, it is crucial to maintain aseptic technique to prevent infections. Changing the central line dressing with sterile technique helps reduce the risk of introducing pathogens into the client's system. Choices A, B, and C are incorrect because changing the TPN tubing every 72 hours, monitoring blood glucose, and monitoring urine output are important aspects of care but are not directly related to preventing infection in clients receiving TPN.

4. How should a healthcare professional assess a patient for dehydration?

• A. Check for skin turgor
• B. Monitor blood pressure
• C. Check for dry mucous membranes
• D. Monitor urine output

Correct answer: A

Rationale: Checking for skin turgor is a reliable method to assess dehydration in patients. Skin turgor refers to the skin's elasticity and hydration status. When a healthcare professional gently pinches the skin on the back of the patient's hand or forearm, dehydration is indicated by the skin not snapping back immediately. Monitoring blood pressure (choice B) is important but is more indicative of cardiovascular status rather than dehydration specifically. Checking for dry mucous membranes (choice C) can be a sign of dehydration, but skin turgor is a more direct assessment. Monitoring urine output (choice D) is also essential but may not provide immediate feedback on hydration status as skin turgor does.

5. A nurse is planning care for a client who has diabetes insipidus and is receiving desmopressin. Which of the following should the nurse monitor?

• A. Fasting blood glucose
• B. Carbohydrate intake
• C. Hematocrit
• D. Weight

Correct answer: D

Rationale: The correct answer is D: Weight. Weight monitoring is essential to assess the effectiveness of desmopressin therapy, as fluid retention is a common side effect. Monitoring fasting blood glucose (choice A) is not directly related to desmopressin therapy for diabetes insipidus. Monitoring carbohydrate intake (choice B) may be important in diabetes management but is not specific to desmopressin therapy. Hematocrit (choice C) monitoring is not a primary concern when managing diabetes insipidus with desmopressin.

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