Nursing Elites

1. An older adult client with chronic emphysema is admitted with acute onset of weakness, palpitation, and vomiting. Which information is most important for the nurse to obtain during the initial interview?

• A. Medication compliance over the past few weeks.
• B. Recent sleep patterns and rest.
• C. Recent history of smoking.
• D. Activity level prior to symptom onset.

Correct answer: A

Rationale: The correct answer is A: Medication compliance over the past few weeks. In a client with chronic emphysema experiencing acute symptoms, it is crucial to assess medication compliance as it directly impacts symptom control and disease management. Ensuring the client has been adherent to their prescribed medications can provide insights into potential exacerbating factors or the need for adjustments in the treatment plan. Choices B, C, and D are less critical during the initial assessment compared to medication compliance. Recent sleep patterns and rest (choice B) may be relevant but are secondary to ensuring proper medication management. While smoking history (choice C) is important in chronic lung conditions, the immediate focus should be on the current status of medication use. Activity level prior to symptom onset (choice D) is also pertinent but not as crucial as confirming medication compliance to address the acute symptoms.

2. A client with a history of deep vein thrombosis (DVT) is prescribed warfarin. Which laboratory value should the nurse monitor to assess the therapeutic effect of this medication?

• A. Platelet count
• B. Prothrombin time (PT)
• C. White blood cell count
• D. Hemoglobin level

Correct answer: B

Rationale: Prothrombin time (PT) is the correct laboratory value to monitor to assess the therapeutic effect of warfarin. Warfarin works by inhibiting clotting factors, and PT measures the time it takes for blood to clot. Monitoring PT helps ensure that the medication is working effectively to prevent clot formation without causing excessive bleeding. Platelet count (Choice A) is not specific to warfarin therapy and assesses the number of platelets in the blood. White blood cell count (Choice C) and hemoglobin level (Choice D) are not directly related to monitoring the therapeutic effect of warfarin.

3. A client receiving lactulose for hepatic encephalopathy needs evaluation. Which assessment should the nurse prioritize?

• A. Percussion of the abdomen.
• B. Blood glucose level.
• C. Serum electrolytes.
• D. Level of consciousness.

Correct answer: D

Rationale: The correct answer is D: Level of consciousness. When managing hepatic encephalopathy with lactulose, monitoring the client's level of consciousness is crucial as it is a key indicator of the therapeutic response to lactulose in reducing ammonia levels. Changes in consciousness can reflect the effectiveness of treatment and the progression of hepatic encephalopathy. Option A, percussion of the abdomen, is not directly related to evaluating the response to lactulose. Option B, blood glucose level, is important but not the priority in this context. Option C, serum electrolytes, while significant in liver disease, do not directly assess the impact of lactulose therapy on hepatic encephalopathy.

4. The nurse is caring for a preterm newborn with nasal flaring, grunting, and sternal retractions. After administering surfactant, which assessment is most important for the nurse to monitor?

• A. Bowel sounds
• B. Heart rate
• C. Arterial blood gases
• D. Apnea episodes

Correct answer: C

Rationale: Corrected Rationale: Surfactant therapy is used to improve lung function and gas exchange in premature infants with respiratory distress. Monitoring arterial blood gases is essential to assess the effectiveness of the treatment and ensure adequate oxygenation. While monitoring heart rate is important in neonatal care, assessing arterial blood gases will provide direct information regarding the infant's oxygenation status post-surfactant administration. Bowel sounds are not directly related to the respiratory distress symptoms described, and monitoring apnea episodes, although important in preterm infants, is not the most crucial assessment immediately following surfactant administration.

5. While changing a client's chest tube dressing, the nurse notes a cracking sensation when gentle pressure is applied to the skin at the insertion site. What should the nurse do next?

• A. Apply a pressure dressing at the chest tube site.
• B. Administer an oral antihistamine per PRN order.
• C. Assess the client for allergies to topical cleaning agents.
• D. Measure the area of crackling and swelling.

Correct answer: D

Rationale: Measuring the area of crackling and swelling is essential in monitoring the progression of subcutaneous emphysema, which can result from air leaking into the tissues around the chest tube insertion site. This technique helps evaluate the extent of the issue and guides further interventions. Applying a pressure dressing (choice A) might exacerbate the condition by trapping more air. Administering an oral antihistamine (choice B) is not indicated for subcutaneous emphysema. Assessing for allergies to topical cleaning agents (choice C) is not the priority in this situation compared to evaluating and managing the subcutaneous emphysema.

Similar Questions