Nursing Elites

1. After an older client receives treatment for drug toxicity, the healthcare provider prescribes a 24-hour creatinine clearance test. Before starting the urine collection, the nurse noted that the client's serum creatinine was 0.3 mg/dL. Which action should the nurse implement?

• A. Check the client's urine output hourly
• B. Instruct the client to increase fluid intake
• C. Notify the healthcare provider of the results
• D. Start the 24-hour urine collection

Correct answer: C

Rationale: A serum creatinine level of 0.3 mg/dL is abnormally low, indicating potential issues with the interpretation of the creatinine clearance test. It is crucial for the nurse to notify the healthcare provider of this result before proceeding with the 24-hour urine collection. Checking urine output, instructing the client to increase fluid intake, or starting the urine collection without consulting the healthcare provider could lead to incorrect test results and misinterpretation of the client's renal function.

2. What information should the nurse include in the client's health record after a fall in the bathroom?

• A. Client fell while trying to go to the bathroom
• B. The UAP left the client alone and a fall occurred
• C. The client was found on the floor with no pulse
• D. The client fell, sustaining a fracture to the left hip

Correct answer: D

Rationale: The correct answer is D because the nurse should document factual, objective information such as the injury sustained by the client. Reporting the specific injury, like a fracture to the left hip, is crucial for accurate medical records. Choices A, B, and C lack specific detail about the injury and focus on different aspects of the fall that are not as pertinent for the health record. Choice A only mentions the fall without specifying the injury, choice B introduces blame without focusing on the client's condition, and choice C adds unnecessary information about the client's pulse which is not directly related to the fall injury.

3. Which meal option should the nurse recommend for a client with renal disease who is following a low-protein diet?

• A. Grilled chicken with steamed vegetables
• B. Tofu stir-fry with rice
• C. Pasta with marinara sauce
• D. Baked salmon with quinoa

Correct answer: C

Rationale: The correct answer is C: Pasta with marinara sauce. Clients with renal disease following a low-protein diet should opt for lower-protein options. Pasta with marinara sauce is a suitable choice as it is lower in protein compared to grilled chicken, tofu, or salmon. Grilled chicken, tofu, and salmon are higher in protein content and are not ideal for individuals following a low-protein diet for renal disease as they may strain the kidneys.

4. The nurse is caring for a client with acute pancreatitis who is reporting severe abdominal pain. Which nursing intervention should the nurse implement first?

• A. Assess the client's bowel sounds
• B. Administer prescribed pain medication
• C. Encourage the client to sit upright
• D. Provide clear fluids to the client

Correct answer: B

Rationale: In a client with acute pancreatitis experiencing severe abdominal pain, the priority nursing intervention is to provide pain relief. Administering prescribed pain medication is essential to improve comfort and reduce pain, which can help stabilize the client's condition. Assessing bowel sounds (Choice A) may be necessary but is not the immediate priority over pain management. Encouraging the client to sit upright (Choice C) and providing clear fluids (Choice D) are not the primary interventions for addressing severe abdominal pain in acute pancreatitis.

5. A client in labor is experiencing late decelerations in fetal heart rate. What intervention should the nurse perform first?

• A. Reposition the client onto her left side.
• B. Apply oxygen via nasal cannula.
• C. Prepare for an emergency cesarean section.
• D. Increase IV fluid administration to improve perfusion.

Correct answer: A

Rationale: Late decelerations indicate fetal distress due to compromised placental perfusion. Repositioning the client onto her left side is the priority intervention as it can increase blood flow to the placenta, improving fetal oxygenation. Applying oxygen via nasal cannula (choice B) can be the next step after repositioning if late decelerations persist. Emergency cesarean section (choice C) is not the initial action for late decelerations unless other interventions are ineffective. Increasing IV fluid administration (choice D) is not the first-line intervention for late decelerations; repositioning takes precedence to address the underlying cause.

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