Nursing Elites

1. After receiving lactulose, a client with hepatic encephalopathy has several loose stools. What action should the nurse implement?

• A. Send stool specimen to the lab
• B. Measure abdominal girth
• C. Encourage increased fiber in the diet
• D. Monitor mental status

Correct answer: D

Rationale: The correct action for the nurse to implement after a client with hepatic encephalopathy has loose stools following lactulose administration is to monitor the client's mental status. Lactulose is given to lower serum ammonia levels in hepatic encephalopathy, and loose stools can be an expected side effect of its use. Monitoring mental status is crucial because changes in mental status, such as confusion or altered level of consciousness, are key indicators of hepatic encephalopathy worsening. Sending a stool specimen to the lab would not be the priority in this situation as loose stools are a known effect of lactulose. Measuring abdominal girth is more relevant for conditions like ascites, not loose stools. Encouraging increased fiber in the diet may be beneficial for constipation but is not the immediate action needed when loose stools occur after lactulose administration.

2. A client with chronic kidney disease (CKD) is scheduled for a renal biopsy. Which laboratory value is most concerning?

• A. Serum potassium of 5.5 mEq/L
• B. Serum creatinine of 1.5 mg/dl
• C. Serum creatinine of 2.5 mg/dl
• D. White blood cell count of 8,000/mm3

Correct answer: C

Rationale: A serum creatinine level of 2.5 mg/dl is the most concerning laboratory value in a client with chronic kidney disease scheduled for a renal biopsy. An elevated serum creatinine level indicates impaired kidney function, which is critical information before performing a renal biopsy. Option A (Serum potassium of 5.5 mEq/L) may be concerning for hyperkalemia but is not directly related to the renal biopsy procedure. Option B (Serum creatinine of 1.5 mg/dl) is within normal limits, suggesting relatively normal kidney function. Option D (White blood cell count of 8,000/mm3) is within the normal range and not directly related to the renal biopsy procedure or CKD management.

3. A client with a history of rheumatoid arthritis is prescribed methotrexate. Which laboratory value should the nurse monitor closely?

• A. Liver function tests
• B. Complete blood count
• C. Serum creatinine
• D. Prothrombin time

Correct answer: C

Rationale: Serum creatinine should be closely monitored in a client receiving methotrexate, as the medication can cause nephrotoxicity. Monitoring serum creatinine levels helps assess kidney function and detect potential nephrotoxic effects of methotrexate. Liver function tests (Choice A) are important to monitor for hepatotoxicity caused by methotrexate. While methotrexate can cause bone marrow suppression, leading to anemia, leukopenia, and thrombocytopenia, monitoring a complete blood count (Choice B) is essential but not the priority in this case. Prothrombin time (Choice D) is not typically affected by methotrexate therapy and is not the primary laboratory value to monitor in this situation.

4. A newly graduated female staff nurse requests reassignment to another client because a male client is asking her for a date and making suggestive comments. Which response is best for the nurse manager to provide?

• A. I have to call the supervisor to get someone else to transfer to this unit to care for him.
• B. I know you are a good nurse and can handle this client in a professional manner.
• C. I'll talk to the client about his behavior and insist that he stop it immediately.
• D. I'll change your assignment, but let's talk about how a nurse should respond to this kind of client.

Correct answer: D

Rationale: The best response for the nurse manager to provide in this situation is option D, which involves changing the assignment to address the nurse's immediate concern. It also offers an opportunity to have a conversation with the nurse about how to professionally handle such situations in the future. Option A is not the best response as it does not address the underlying issue and simply shifts the problem to another staff member. Option B, while supportive, does not actively address the client's inappropriate behavior. Option C is not ideal as the nurse manager should handle discussions about inappropriate behavior with clients themselves rather than delegating it to the staff nurse.

5. The nurse is caring for a client with a history of atrial fibrillation who is receiving warfarin (Coumadin). Which laboratory value should be closely monitored?

• A. Serum potassium level
• B. Prothrombin time (PT)
• C. International Normalized Ratio (INR)
• D. Serum sodium level

Correct answer: C

Rationale: The correct answer is C, International Normalized Ratio (INR). The INR should be closely monitored in a client receiving warfarin (Coumadin) to assess the effectiveness and safety of anticoagulation therapy. Monitoring the INR helps ensure that the client is within the therapeutic range for anticoagulation to prevent complications such as bleeding or clotting. Choices A, B, and D are incorrect. While monitoring electrolyte levels like serum potassium and sodium is important in overall client care, they are not specific to monitoring the effects of warfarin therapy. Prothrombin time (PT) is a component of INR and helps in monitoring warfarin therapy, but INR gives a standardized result that is independent of the laboratory method used, making it the preferred choice for monitoring warfarin therapy.

Similar Questions