Nursing Elites

1. The nurse enters a client's room and observes the unlicensed assistive personnel (UAP) making an occupied bed as seen in the picture. What action should the nurse take first?

• A. Place the side rails in an up position.
• B. Assist the UAP in turning the client.
• C. Provide instructions on proper bed-making techniques.
• D. Ask the client if they are comfortable.

Correct answer: A

Rationale: Correct Answer: The nurse should first place the side rails in an up position. This action is crucial to prevent the client from falling while the bed is being made. Choice B is incorrect as moving or turning the client is not necessary at this point. Choice C is not a priority when immediate safety concerns are present. Choice D, asking the client if they are comfortable, though important, should come after ensuring the client's safety by raising the side rails.

2. A client with end-stage renal disease (ESRD) is scheduled for hemodialysis. Which laboratory value should be closely monitored before the procedure?

• A. Serum creatinine of 2.0 mg/dl
• B. Serum potassium of 5.5 mEq/L
• C. Serum calcium of 8.0 mg/dl
• D. Hemoglobin of 12 g/dl

Correct answer: B

Rationale: A serum potassium level of 5.5 mEq/L is concerning in a client with ESRD scheduled for hemodialysis as it indicates hyperkalemia, which can lead to serious cardiac complications. Hyperkalemia can be exacerbated during hemodialysis, making it crucial to closely monitor serum potassium levels before the procedure. Monitoring serum creatinine, serum calcium, or hemoglobin levels is important in managing ESRD but is not the immediate focus before hemodialysis. Therefore, option B is the correct choice.

3. The nurse is assessing a client with left-sided heart failure. Which finding requires immediate intervention?

• A. Shortness of breath
• B. Jugular venous distention
• C. Crackles in the lungs
• D. Peripheral edema

Correct answer: C

Rationale: Crackles in the lungs indicate pulmonary congestion in a client with left-sided heart failure and require immediate intervention to prevent respiratory failure. Crackles suggest fluid accumulation in the lungs, leading to impaired gas exchange and potentially respiratory distress. Shortness of breath, jugular venous distention, and peripheral edema are common manifestations of heart failure but do not directly indicate acute respiratory compromise like crackles in the lungs do.

4. A client with a history of chronic kidney disease (CKD) is receiving erythropoietin therapy. Which assessment finding is most concerning?

• A. Increased fatigue
• B. Headache
• C. Elevated blood pressure
• D. Low urine output

Correct answer: C

Rationale: In a client with chronic kidney disease receiving erythropoietin therapy, elevated blood pressure is the most concerning assessment finding. Erythropoietin can increase red blood cell production, leading to thicker blood, which in turn can elevate blood pressure. Elevated blood pressure in this scenario may indicate worsening hypertension, which requires prompt intervention to prevent complications such as stroke, heart attack, or further kidney damage. Increased fatigue (choice A) is a common symptom in CKD patients and can be expected with erythropoietin therapy. Headache (choice B) can occur but is less concerning than elevated blood pressure in this context. Low urine output (choice D) is a significant finding in CKD, but in a client receiving erythropoietin, elevated blood pressure takes precedence due to its potential for immediate adverse effects.

5. The nurse is assessing a female client's blood pressure because she reported feeling dizzy. The blood pressure cuff is inflated to 140 mm Hg and as soon as the cuff is deflated a Korotkoff sound is heard. Which intervention should the nurse implement next?

• A. Wait 1 minute and palpate the systolic pressure before auscultating again.
• B. Increase the inflation pressure by 20 mm Hg and measure again.
• C. Switch to a larger cuff and repeat the measurement.
• D. Document the finding as normal.

Correct answer: A

Rationale: If a Korotkoff sound is heard immediately upon deflation, it may indicate an inaccurate reading. Waiting and palpating the systolic pressure can help confirm the accuracy of the measurement. Choice A is the correct intervention because it allows the nurse to ensure the accuracy of the blood pressure reading. Choice B is incorrect as increasing the inflation pressure is not necessary in this situation. Choice C is also incorrect as switching to a larger cuff is not warranted based on the information provided. Choice D is incorrect because documenting the finding as normal without further verification could lead to inaccurate information.

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