Nursing Elites

1. The nurse discontinues a continuous IV heparin infusion for a male client on strict bedrest and is now preparing to administer the client's first dose of enoxaparin. Prior to giving this subcutaneous injection, which assessment finding requires additional intervention by the nurse?

• A. Current lab report indicates an Aptt at 1.5 times the client's control
• B. The client states that his right calf is aching and wants pain medication
• C. The spouse is assisting the client who is shaving with an electric razor
• D. Several bruised areas are noted on the client's upper extremities bilaterally

Correct answer: D

Rationale: The correct answer is D. Bruised areas on the client's upper extremities bilaterally indicate an increased risk of bleeding, which requires careful assessment before administering enoxaparin. Bruising suggests potential issues with clotting and hemostasis, making it crucial for the nurse to further evaluate the client's bleeding risk. Choices A, B, and C do not directly relate to the assessment of bleeding risk associated with enoxaparin administration and are therefore incorrect. Choice A provides information about the client's Aptt, which is not directly relevant to assessing bleeding risk for enoxaparin. Choice B addresses pain management, and Choice C involves the client's daily activities with no direct link to the bleeding risk assessment.

2. A client with osteoporosis related to long-term corticosteroid therapy receives a prescription for calcium carbonate. Which client’s serum laboratory value requires intervention by the nurse?

• A. Total calcium 9 mg/dl (2.25 mmol/L SI)
• B. Creatinine 4 mg/dl (354 micromol/L SI)
• C. Phosphate 4 mg/dl (1.293 mmol/L SI)
• D. Fasting glucose 95 mg/dl (5.3 mmol/L SI)

Correct answer: B

Rationale: An elevated creatinine level indicates possible renal impairment, which requires intervention. High creatinine levels are associated with decreased kidney function, and in this case, it suggests potential renal issues due to long-term corticosteroid therapy. Monitoring renal function is crucial in clients with osteoporosis on corticosteroid therapy to prevent further complications. Total calcium levels within the normal range are suitable for a client with osteoporosis receiving calcium carbonate. Phosphate and fasting glucose levels do not directly indicate renal impairment in this scenario.

3. The nurse is assessing a client with Addison's disease who is weak, dizzy, disoriented, and has dry oral mucous membranes, poor skin turgor, and sunken eyes. Vital signs are blood pressure 94/44, heart rate 123 beats/minute, respiration 22 breaths/minute. Which intervention should the nurse implement first?

• A. Assess extremity strength and resistance
• B. Report a sodium level of 132 mEq/L or mmol/L (SI units)
• C. Measure and record the cardiac QRS complex
• D. Check current finger stick glucose

Correct answer: D

Rationale: The client’s symptoms suggest possible adrenal crisis or hypoglycemia. Checking glucose is a priority to rule out hypoglycemia, which requires immediate intervention. The client is presenting with symptoms indicative of hypoglycemia, which can be life-threatening if not promptly addressed. Assessing extremity strength, reporting sodium levels, or measuring the cardiac QRS complex are not the most urgent actions in this scenario.

4. A nurse working on an endocrine unit should see which client first?

• A. An adolescent male with diabetes who is arguing about his insulin dose.
• B. An older client with Addison’s disease whose current blood sugar level is 62mg/dl (3.44 mmol/l).
• C. An adult with a blood sugar of 384mg/dl (21.31mmol/l) and urine output of 350 ml in the last hour.
• D. A client taking corticosteroids who has become disoriented in the last two hours.

Correct answer: B

Rationale: The correct answer is B. The client with Addison’s disease and a blood sugar level of 62mg/dl (3.44 mmol/l) is experiencing hypoglycemia, which can progress to adrenal crisis. This situation requires immediate attention to prevent further complications. Choices A, C, and D, although concerning, do not pose an immediate life-threatening risk compared to the client with Addison’s disease and hypoglycemia. The adolescent arguing about his insulin dose can be addressed after stabilizing the client with Addison’s disease. The adult with high blood sugar and increased urine output may have hyperglycemia but is not in immediate danger. The client taking corticosteroids who is disoriented needs evaluation but is not in an acute life-threatening condition as the client with hypoglycemia.

5. A client with acute renal failure (ARF) is admitted for uncontrolled type 1 diabetes mellitus and hyperkalemia. The nurse administers an IV dose of regular insulin per sliding scale. Which intervention is the most important for the nurse to include in this client’s plan of care?

• A. Monitor the client’s cardiac activity via telemetry.
• B. Maintain venous access with an infusion of normal saline.
• C. Assess glucose levels via finger stick every 4 to 6 hours.
• D. Evaluate hourly urine output for the return of normal renal function.

Correct answer: A

Rationale: Monitoring cardiac activity is crucial in this scenario because hyperkalemia can lead to serious cardiac dysrhythmias, which can be life-threatening. Regular monitoring of the client’s cardiac activity via telemetry allows for early detection of any potential cardiac complications. Maintaining venous access with a normal saline infusion is important for hydration but does not address the immediate risk of cardiac dysrhythmias posed by hyperkalemia. Assessing glucose levels is essential in diabetes management but is not the priority when dealing with hyperkalemia-induced cardiac risks. Evaluating hourly urine output for the return of normal renal function is important in ARF but is not as urgent as monitoring the client's cardiac activity in the context of hyperkalemia.

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