Nursing Elites

1. A nurse is reviewing the medical record of a client who was admitted for acute kidney injury. Which of the following laboratory values should the nurse expect to be elevated?

• A. Creatinine
• B. Magnesium
• C. Hemoglobin
• D. White blood cell count

Correct answer: A

Rationale: Creatinine is the correct answer. In acute kidney injury, creatinine levels are expected to be elevated due to impaired renal function. Magnesium, hemoglobin, and white blood cell count are not typically elevated in acute kidney injury. Magnesium levels may be affected in kidney disease, but elevation is not a common finding in acute kidney injury.

2. A nurse is planning care for a school-age child who is 4 hr postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care?

• A. Offer small amounts of clear liquids 6 hr following surgery.
• B. Give cromolyn nebulizer solution every 6 hr.
• C. Apply a warm compress to the operative site every 4 hr.
• D. Administer analgesics on a scheduled basis for the first 24 hr.

Correct answer: D

Rationale: Administering analgesics on a scheduled basis for the first 24 hours is crucial to ensure adequate pain control in the immediate postoperative period. Choice A is incorrect because clear liquids are typically initiated gradually and advanced as tolerated but not specifically at 6 hours post-surgery. Choice B is incorrect as cromolyn nebulizer solution is not indicated for postoperative pain management in this scenario. Choice C is incorrect as applying a warm compress may not be appropriate for the operative site after appendicitis surgery and can potentially increase the risk of infection.

3. Which intervention is essential when caring for a client with heart failure on fluid restriction?

• A. Encourage the client to drink water throughout the day
• B. Monitor the client's weight daily to assess fluid balance
• C. Limit fluid intake during meals
• D. Weigh the client once a week to assess fluid balance

Correct answer: B

Rationale: The correct answer is B: 'Monitor the client's weight daily to assess fluid balance.' When caring for a client with heart failure on fluid restriction, it is essential to monitor their weight daily to evaluate fluid balance accurately. This helps healthcare providers assess if the client is retaining excess fluid, a common issue in heart failure. Choices A, C, and D are incorrect. Encouraging the client to drink water throughout the day contradicts fluid restriction. Limiting fluid intake during meals may not provide a comprehensive assessment of fluid balance, and weighing the client once a week is not frequent enough to detect rapid changes in fluid status that could worsen heart failure symptoms.

4. How should a healthcare provider assess and manage a patient with a potential myocardial infarction (MI)?

• A. Assess symptoms, monitor vital signs, order ECG
• B. Administer medications and monitor for pain
• C. Administer thrombolytics and oxygen therapy
• D. Educate patient on lifestyle changes

Correct answer: A

Rationale: Correct Answer: A. When assessing a patient with a potential myocardial infarction, it is crucial to assess symptoms, monitor vital signs like blood pressure and heart rate, and order an electrocardiogram (ECG) to evaluate for cardiac abnormalities. Choice B is incorrect because administering medications should be based on the findings of the assessment and diagnostic tests, not administered indiscriminately. Choice C is incorrect because the administration of thrombolytics and oxygen therapy should be based on specific criteria and should be done in a controlled setting. Choice D is incorrect as educating the patient on lifestyle changes is important for prevention but is not the immediate priority when managing a potential myocardial infarction.

5. A nurse on a med surge unit has received change of shift report and will care for 4 clients. Which of the following clients' needs will the nurse assign to an AP?

• A. Feeding a client who was admitted 24 hours ago with aspiration pneumonia
• B. Reinforcing teaching with a client who is learning to walk with a quad cane
• C. Reapplying a condom catheter for a client who has urinary incontinence
• D. Applying a sterile dressing to a pressure ulcer

Correct answer: C

Rationale: The correct answer is C because reapplying a condom catheter for a client with urinary incontinence is a task that can be safely assigned to an assistive personnel (AP) as it falls within their scope of practice. Choice A involves the assessment of a client with aspiration pneumonia, which requires nursing judgment. Choice B requires teaching and guidance, which is the responsibility of the nurse. Choice D involves applying a sterile dressing, which requires nursing skills and knowledge.

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