Nursing Elites

1. A young male client is admitted to rehabilitation following a right AKA (above-the-knee amputation) for a severe traumatic injury. He is in the commons room and anxiously calls out to the nurse, stating that his 'right foot is aching.' The nurse offers reassurance and support. Which additional intervention is most important for the nurse to implement?

• A. Teach the client distraction techniques
• B. Provide a soft blanket to ease discomfort
• C. Administer prescribed pain medication
• D. Encourage discussion of feelings about the loss of his limb

Correct answer: D

Rationale: The client's report of pain in a missing limb is consistent with phantom limb pain, which can be distressing. Encouraging the client to discuss his feelings helps address the emotional and psychological aspects of the amputation and supports his overall recovery. Teaching distraction techniques (choice A) may provide temporary relief but does not address the underlying emotional distress. Providing a soft blanket (choice B) is not the priority when dealing with phantom limb pain. Administering pain medication (choice C) may not effectively manage phantom limb pain as it is more related to central nervous system changes rather than tissue damage.

2. A client with deep vein thrombosis (DVT) is prescribed heparin therapy. What laboratory value should the nurse monitor?

• A. Monitor the client’s liver function tests.
• B. Monitor the client’s prothrombin time (PT).
• C. Monitor the client’s partial thromboplastin time (PTT).
• D. Monitor the client’s red blood cell count.

Correct answer: C

Rationale: The correct answer is C: Monitor the client’s partial thromboplastin time (PTT). During heparin therapy for DVT, it is essential to monitor the PTT to assess the effectiveness of the medication in preventing clot formation. Monitoring the PTT helps ensure that the client is within the therapeutic range for anticoagulation. Choices A, B, and D are incorrect because liver function tests, prothrombin time (PT), and red blood cell count are not specifically monitored to assess the effectiveness of heparin therapy in preventing clot formation.

3. Which of these findings should the nurse report immediately after a client has a liver biopsy?

• A. Temperature of 99.5 degrees F (37.5 degrees C)
• B. Blood pressure of 108/70
• C. Pulse oximetry reading of 96%
• D. Severe abdominal pain

Correct answer: D

Rationale: The correct answer is D, severe abdominal pain. After a liver biopsy, severe abdominal pain is a critical finding that requires immediate reporting as it may indicate internal bleeding or damage to the liver. The other vital signs provided in choices A, B, and C are within normal limits and may not be directly related to complications post liver biopsy. Therefore, the priority is to address the severe abdominal pain promptly to prevent any further complications.

4. The nurse is providing care for a client with heart failure who is prescribed furosemide. Which laboratory value should the nurse monitor closely?

• A. Calcium level
• B. Sodium level
• C. Magnesium level
• D. Potassium level

Correct answer: D

Rationale: The correct answer is D: Potassium level. Furosemide is a loop diuretic that can cause potassium loss, leading to hypokalemia. Monitoring potassium levels is crucial to prevent complications such as cardiac arrhythmias. While calcium, sodium, and magnesium levels are important in various conditions and treatments, they are not the primary electrolyte affected by furosemide.

5. A client with acute kidney injury (AKI) is experiencing hyperkalemia. What intervention should the nurse prioritize?

• A. Administer IV calcium gluconate.
• B. Administer sodium polystyrene sulfonate (Kayexalate).
• C. Administer insulin with dextrose.
• D. Restrict potassium intake in the client's diet.

Correct answer: A

Rationale: The correct intervention for a client with acute kidney injury (AKI) experiencing hyperkalemia is to administer IV calcium gluconate. Calcium gluconate helps stabilize the myocardium and prevent life-threatening arrhythmias in hyperkalemia by antagonizing the cardiac effects of high potassium levels. Choice B, administering sodium polystyrene sulfonate (Kayexalate), is used to lower potassium levels in the gastrointestinal tract but is not the priority in acute severe hyperkalemia. Choice C, administering insulin with dextrose, helps drive potassium into cells but is not the priority in a client at risk for arrhythmias due to hyperkalemia. Choice D, restricting potassium intake in the client's diet, is a long-term strategy but is not the immediate priority in managing acute hyperkalemia.

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