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. In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration and the client's respiratory rate is 14 breaths/minute. What action should the nurse implement?

• A. Encourage the client to take deep breaths
• B. Remove the mask to deflate the bag
• C. Increase the liter flow of oxygen
• D. Document the assessment data

Correct answer: D

Rationale: The correct action for the nurse to implement is to document the assessment data. In this scenario, the findings indicate that the partial rebreather mask is functioning correctly as the reservoir bag should not deflate completely during inspiration. Additionally, the client's respiratory rate of 14 breaths/minute falls within the normal range. There is no need to encourage the client to take deep breaths, as the respiratory rate is normal, and doing so may disrupt the client's breathing pattern. Removing the mask to deflate the bag or increasing the liter flow of oxygen are unnecessary actions based on the assessment findings.

3. The nurse is caring for a client with diabetic ketoacidosis (DKA). Which laboratory value requires immediate intervention?

• A. Serum glucose of 300 mg/dL
• B. Serum potassium of 4.5 mEq/L
• C. Serum bicarbonate of 15 mEq/L
• D. Serum pH of 7.28

Correct answer: D

Rationale: A serum pH of 7.28 indicates metabolic acidosis in a client with diabetic ketoacidosis (DKA), requiring immediate intervention. In DKA, the body produces excess ketones, leading to acidosis. Monitoring and correcting the pH level is crucial in managing DKA. Serum glucose levels may be high in DKA, but the immediate concern is correcting the acidosis to prevent complications. Serum potassium and bicarbonate levels are also important but not as immediately critical as correcting the acidosis in DKA.

4. A client with end-stage renal disease (ESRD) is scheduled for hemodialysis. Which laboratory value should the nurse report to the healthcare provider immediately?

• A. Serum potassium of 5.5 mEq/L
• B. Serum calcium of 8 mg/dL
• C. Serum creatinine of 2.0 mg/dL
• D. White blood cell count of 10,000/mm³

Correct answer: A

Rationale: A serum potassium level of 5.5 mEq/L is concerning in a client with ESRD scheduled for hemodialysis as it indicates hyperkalemia, requiring immediate intervention. Hyperkalemia can lead to serious cardiac arrhythmias, especially during hemodialysis. Serum calcium, serum creatinine, and white blood cell count, while important, do not pose immediate life-threatening risks like hyperkalemia.

5. A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician's office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child's foot. Which action should the nurse implement first?

• A. Cleanse the foot with soap and water and apply an antibiotic ointment
• B. Provide teaching about the need for a tetanus booster within the next 72 hours.
• C. Have the mother check the child's temperature every 4 hours for the next 24 hours
• D. Transfer the child to the emergency department to receive a gamma globulin injection

Correct answer: A

Rationale: The correct first action for the nurse to implement is to cleanse the foot with soap and water and apply an antibiotic ointment to prevent infection. In cases of puncture wounds like stepping on a rusty nail, the immediate concern is to reduce the risk of infection. Providing teaching about the need for a tetanus booster within the next 72 hours is important as well, but it should come after the wound is cleansed. Checking the child's temperature and transferring to the emergency department for a gamma globulin injection are not the immediate priorities in this scenario.

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