Nursing Elites

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

• A. Bilirubin 0.8 mg/dL
• B. Ammonia 35 mcg/dL
• C. Prothrombin time 16 seconds
• D. Albumin 4 g/dL

Correct answer: C

Rationale: In clients with liver cirrhosis, an elevated prothrombin time indicates impaired liver function and decreased production of clotting factors. This finding should be reported to the provider for further evaluation and management. Choices A, B, and D are within normal ranges and do not specifically indicate worsening liver cirrhosis. Bilirubin 0.8 mg/dL is normal, ammonia 35 mcg/dL is within the reference range, and albumin 4 g/dL is also within the normal range for this client population.

2. A nurse is assessing a client who has increased intracranial pressure (ICP). Which of the following findings should the nurse expect?

• A. Bradycardia.
• B. Increased level of consciousness.
• C. Tachycardia.
• D. Hyperactive bowel sounds.

Correct answer: C

Rationale: The correct answer is C: Tachycardia. In a client with increased intracranial pressure (ICP), tachycardia is a common finding. This is due to the body's compensatory mechanisms in response to the increased pressure. Bradycardia (choice A) is not typically associated with increased ICP and may indicate a different issue. Increased level of consciousness (choice B) is unlikely with increased ICP, as it often leads to altered mental status. Hyperactive bowel sounds (choice D) are not directly related to increased ICP and are more indicative of gastrointestinal issues.

3. A nurse is planning care for a client who has a prescription for a bowel-training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care?

• A. Encourage a maximum fluid intake of 1,500 ml per day.
• B. Increase the intake of refined grains in the client's diet.
• C. Provide the client with a cold drink prior to defecation.
• D. Administer a rectal suppository 30 minutes prior to scheduled defecation times.

Correct answer: D

Rationale: Administering a rectal suppository 30 minutes before scheduled defecation times is essential in a bowel-training program following a spinal cord injury. The suppository helps stimulate bowel movements and aids in establishing a regular bowel routine. Encouraging a maximum fluid intake of 1,500 ml per day (Choice A) might be beneficial for bowel function, but it is not specific to the bowel-training program. Increasing the intake of refined grains in the diet (Choice B) is not necessary and could potentially lead to constipation rather than improving bowel movements. Providing a cold drink prior to defecation (Choice C) may not directly contribute to the effectiveness of the bowel-training program compared to the use of a rectal suppository.

4. A nurse is caring for a client who has a pulmonary embolism. The nurse should identify which finding as an indication of effective treatment?

• A. A chest x-ray reveals increased density in all lung fields.
• B. The client reports feeling less anxious.
• C. Diminished breath sounds are auscultated bilaterally.
• D. ABG results include a pH of 7.48, PaO2 77 mm Hg, and PaCO2 47 mm Hg.

Correct answer: B

Rationale: The correct answer is B. The client reporting feeling less anxious is a positive indication of effective treatment for a pulmonary embolism. This suggests that the client's condition is improving psychologically. Option A is incorrect because increased density in all lung fields on a chest x-ray may indicate unresolved issues related to the embolism. Option C is incorrect as diminished breath sounds bilaterally suggest a complication or worsening of the condition. Option D is incorrect as ABG results within normal range do not necessarily indicate effective treatment for a pulmonary embolism, as other complications may still be present.

5. A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following interventions should the nurse implement?

• A. Provide a low-sodium diet.
• B. Administer lorazepam as prescribed.
• C. Keep the client in a supine position.
• D. Place the client in restraints as prescribed.

Correct answer: B

Rationale: Administering lorazepam is the appropriate intervention for a client experiencing acute alcohol withdrawal. Lorazepam helps reduce agitation and prevent complications during this withdrawal phase. Choice A, providing a low-sodium diet, is not directly related to managing alcohol withdrawal symptoms. Choice C, keeping the client in a supine position, is not necessary and may not address the client's withdrawal symptoms. Choice D, placing the client in restraints, should only be considered if the client is at risk of harming themselves or others, but it is not the primary intervention for managing alcohol withdrawal.

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