Nursing Elites

1. During the initial newborn assessment, the nurse finds that a newborn's heart rate is irregular. Which intervention should the nurse implement?

• A. Notify the pediatrician immediately.
• B. Teach the parents about congenital heart defects.
• C. Document the finding in the infant's record.
• D. Apply oxygen via nasal cannula at 3 L/min.

Correct answer: C

Rationale: The correct intervention when a nurse finds an irregular heart rate in a newborn is to document the finding in the infant's record. An irregular heart rate is a common occurrence in newborns and does not necessarily require immediate medical intervention. Notifying the pediatrician immediately is unnecessary unless there are other concerning symptoms. Teaching the parents about congenital heart defects is not the priority in this situation. Applying oxygen via nasal cannula at 3 L/min is not indicated for an irregular heart rate without further assessment or medical indication.

2. A client with cirrhosis is admitted with jaundice and ascites. Which assessment finding requires immediate intervention?

• A. Peripheral edema
• B. Confusion and altered mental status
• C. Yellowing of the skin
• D. Increased abdominal girth

Correct answer: B

Rationale: Confusion and altered mental status are the most critical assessment findings in a client with cirrhosis. These symptoms may indicate hepatic encephalopathy, a serious complication that requires immediate intervention. Yellowing of the skin (jaundice) is a common manifestation of cirrhosis and does not necessitate immediate intervention. Peripheral edema and increased abdominal girth are associated with fluid retention in cirrhosis but are not as urgent as addressing altered mental status and confusion.

3. A client with liver cirrhosis is admitted with ascites and jaundice. Which assessment finding is most concerning?

• A. Serum albumin of 3.0 g/dL
• B. Bilirubin of 3.0 mg/dL
• C. Ammonia level of 80 mcg/dL
• D. Prothrombin time of 18 seconds

Correct answer: C

Rationale: An ammonia level of 80 mcg/dL is elevated and concerning in a client with liver cirrhosis, as it may indicate hepatic encephalopathy. Elevated ammonia levels can lead to cognitive impairment, altered mental status, and even coma. Serum albumin, bilirubin, and prothrombin time are also important markers in liver cirrhosis but are not as directly associated with the risk of hepatic encephalopathy as elevated ammonia levels.

4. The nurse is caring for a client with acute pancreatitis who is receiving total parenteral nutrition (TPN). Which laboratory value should be monitored closely?

• A. Serum calcium
• B. Serum triglycerides
• C. Serum glucose
• D. Serum triglycerides

Correct answer: B

Rationale: Serum triglycerides should be monitored closely in a client receiving TPN as they may indicate hyperlipidemia, which is a potential complication of TPN. Monitoring serum triglycerides is essential to prevent complications such as hypertriglyceridemia. Serum calcium and glucose levels are also important to monitor in clients receiving TPN, but in this scenario, serum triglycerides take priority due to the risk of hyperlipidemia.

5. A client with type 2 diabetes is admitted with hyperglycemic hyperosmolar syndrome (HHS). Which laboratory value requires immediate intervention?

• A. Serum glucose of 600 mg/dL
• B. Serum osmolarity of 320 mOsm/kg
• C. Serum sodium of 130 mEq/L
• D. Serum potassium of 5.0 mEq/L

Correct answer: B

Rationale: A serum osmolarity of 320 mOsm/kg is concerning in a client with HHS because it indicates severe dehydration and hyperosmolarity, which requires immediate intervention. In HHS, the elevated serum osmolarity leads to neurological symptoms and can result in serious complications if not addressed promptly. While a high serum glucose level (choice A) is typical in HHS, the osmolarity is a more direct indicator of dehydration and severity. Serum sodium (choice C) and potassium levels (choice D) are important but do not pose an immediate threat to the client's condition compared to the severe hyperosmolarity indicated by a high serum osmolarity level.

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