Nursing Elites

1. Following insertion of a LeVeen shunt in a client with cirrhosis of the liver, which assessment finding indicates to the nurse that the shunt is effective?

• A. Decreased abdominal girth
• B. Increased blood pressure
• C. Clear breath sounds
• D. Decreased serum albumin

Correct answer: A

Rationale: The correct answer is A: Decreased abdominal girth. In a client with cirrhosis of the liver, a LeVeen shunt is used to treat ascites, which is the accumulation of fluid in the peritoneal cavity. A decrease in abdominal girth indicates that the shunt is effectively draining the ascitic fluid, relieving the client's abdominal distension. Choice B, increased blood pressure, is incorrect as a LeVeen shunt is not expected to impact blood pressure. Choice C, clear breath sounds, is unrelated to the effectiveness of a LeVeen shunt in managing ascites. Choice D, decreased serum albumin, is also not a direct indicator of the shunt's effectiveness in draining ascitic fluid.

2. A client with chronic kidney disease (CKD) is scheduled for hemodialysis. Which laboratory value should the nurse report to the healthcare provider before the procedure?

• A. Serum potassium of 5.5 mEq/L
• B. Hemoglobin of 10 g/dl
• C. Potassium of 6.0 mEq/L
• D. Blood glucose of 200 mg/dl

Correct answer: C

Rationale: The correct answer is C: Potassium of 6.0 mEq/L. A potassium level of 6.0 mEq/L is dangerously high in a client with CKD, and it should be reported before hemodialysis to prevent cardiac complications. High potassium levels can lead to life-threatening arrhythmias. Choices A, B, and D are not the most critical values to report before hemodialysis. While a serum potassium level of 5.5 mEq/L is slightly elevated, it is not as urgent as a level of 6.0 mEq/L in this context. Hemoglobin of 10 g/dl and blood glucose of 200 mg/dl are important parameters to monitor but are not as immediately concerning before hemodialysis compared to a high potassium level.

3. The nurse is caring for a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which laboratory value requires immediate intervention?

• A. Serum potassium of 5.5 mEq/L
• B. Serum creatinine of 2.5 mg/dL
• C. Hemoglobin of 10 g/dL
• D. White blood cell count of 10,000/mm³

Correct answer: A

Rationale: A serum potassium level of 5.5 mEq/L is most concerning in a client receiving erythropoietin therapy as it indicates hyperkalemia, requiring immediate intervention. High potassium levels can lead to severe cardiac arrhythmias and must be addressed promptly. The other laboratory values, though abnormal, do not present immediate life-threatening risks as hyperkalemia does.

4. A client with heart failure is prescribed furosemide (Lasix). Which assessment finding should the nurse report to the healthcare provider immediately?

• A. Heart rate of 60 beats per minute
• B. Blood pressure of 100/60 mmHg
• C. Presence of a new murmur
• D. Crackles in the lungs

Correct answer: D

Rationale: The correct answer is D: Crackles in the lungs. Crackles indicate fluid overload in the lungs, a critical sign in a client with heart failure. This finding suggests that the furosemide may not be effectively managing the fluid balance, and immediate intervention is required. Choices A, B, and C are not immediate concerns in this scenario. A heart rate of 60 beats per minute, a blood pressure of 100/60 mmHg, and the presence of a new murmur are findings that may require monitoring or intervention but are not as urgent as crackles in the lungs in a client with heart failure.

5. A woman who takes pyridostigmine for myasthenia gravis (MG) arrives at the emergency department complaining of extreme muscle weakness. Her adult daughter tells the nurse that since yesterday her mother has been unable to smile. Which assessment finding warrants immediate intervention by the nurse?

• A. Uncontrollable drooling.
• B. Inability to raise voice.
• C. Tingling of extremities.
• D. Eyelid drooping.

Correct answer: A

Rationale: Uncontrollable drooling can be a sign of a myasthenic crisis, which requires immediate medical intervention to prevent respiratory failure. Drooling indicates difficulty in swallowing, which can lead to aspiration and respiratory compromise. Inability to raise voice (choice B) and tingling of extremities (choice C) are not typically associated with myasthenic crisis. Although eyelid drooping (choice D) is a common symptom of myasthenia gravis, it is not as urgent as uncontrollable drooling in indicating a potential crisis.

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