Nursing Elites

1. A healthcare professional is reviewing the laboratory values of a client who has cirrhosis. Which of the following findings should the healthcare professional report to the provider?

• A. Ammonia 75 mcg/dL
• B. Sodium 142 mEq/L
• C. Calcium 9.5 mg/dL
• D. Bilirubin 2.5 mg/dL

Correct answer: D

Rationale: An elevated bilirubin level in clients with cirrhosis indicates worsening liver function and potential complications. It is crucial to report this finding promptly as it may require immediate medical intervention. Elevated ammonia levels (choice A) are also concerning in cirrhosis, indicating hepatic encephalopathy, but bilirubin levels are more specific to liver function in this context. Choices B and C are within normal ranges and are not typically of immediate concern in cirrhosis.

2. A client is 2 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?

• A. Position the client supine with a pillow between the legs.
• B. Place an abduction pillow between the client's legs.
• C. Place a pillow under the client's knees.
• D. Position the client's legs in adduction.

Correct answer: B

Rationale: After a total hip arthroplasty, it is crucial to prevent hip dislocation. Placing an abduction pillow between the client's legs helps maintain proper alignment of the hip joint and prevents adduction, which could lead to dislocation. Therefore, choice B is the correct action. Choice A is incorrect because positioning the client supine with a pillow between the legs does not provide the necessary abduction to prevent dislocation. Choice C, placing a pillow under the client's knees, does not address the need for abduction. Choice D, positioning the client's legs in adduction, is incorrect as adduction increases the risk of hip dislocation following hip arthroplasty.

3. A client with hypertension is receiving discharge teaching from a nurse on managing blood pressure at home. Which of the following instructions should the nurse include?

• A. Take medication at bedtime.
• B. Check blood pressure once a week.
• C. Use a blood pressure cuff that fits snugly around the arm.
• D. Stop taking medication once blood pressure is within the normal range.

Correct answer: C

Rationale: The correct answer is C: 'Use a blood pressure cuff that fits snugly around the arm.' Using a properly fitting cuff is essential for accurate blood pressure measurements. Choice A is incorrect because the timing of medication administration should be individualized and not specified in the question. Choice B is incorrect as checking blood pressure once a week may not provide sufficient monitoring for a client with hypertension. Choice D is incorrect because stopping medication abruptly once blood pressure is normal can lead to rebound hypertension and complications.

4. A nurse is teaching a group of newly licensed nurses about measures to take when caring for a client who is on contact precautions. Which of the following should the nurse include in the teaching?

• A. Remove the protective gown after leaving the client's room
• B. Place the client in a room with positive pressure
• C. Wear gloves when providing care to the client
• D. Wear a mask when entering the client's room

Correct answer: C

Rationale: The correct measure to include when caring for a client on contact precautions is to wear gloves when providing care. Gloves help prevent the spread of infection and cross-contamination. Choice A is incorrect because the protective gown should be removed before leaving the client's room to prevent the spread of pathogens. Choice B is incorrect as clients on contact precautions should be in a room with negative pressure to prevent the spread of airborne contaminants. Choice D is incorrect as wearing a mask when changing linens is not specifically required for contact precautions.

5. A nurse is providing teaching to family members of a client who has dementia. Which of the following instructions should the nurse include?

• A. Establish a toileting schedule for the client.
• B. Use clothing with buttons and zippers.
• C. Discourage physical activity during the day.
• D. Engage the client in activities that increase sensory stimulation.

Correct answer: A

Rationale: The correct answer is A: Establish a toileting schedule for the client. A toileting schedule helps manage incontinence and prevent accidents, promoting client dignity. Choice B is incorrect because clothing with buttons and zippers may be difficult for a client with dementia to manage independently. Choice C is incorrect as physical activity during the day is beneficial for clients with dementia. Choice D is incorrect as activities that increase sensory stimulation may be overwhelming for a client with dementia.

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