Nursing Elites

1. The nurse is assessing a client 2 hours postoperatively following an appendectomy. The nurse should intervene for which abnormal finding?

• A. Heart rate of 88 beats per minute
• B. Blood pressure of 100/60
• C. Oxygen saturation of 94%
• D. Respiratory rate of 16

Correct answer: C

Rationale: The correct answer is C. Oxygen saturation levels below 95% indicate hypoxia and require immediate intervention. A heart rate of 88 beats per minute, a blood pressure of 100/60, and a respiratory rate of 16 are within normal ranges and do not require immediate intervention. Oxygen saturation is a critical parameter reflecting the client's oxygenation status.

2. A client with cirrhosis is admitted with jaundice, fatigue, and a distended abdomen. Which laboratory result is most important for the nurse to monitor?

• A. Ammonia level
• B. White blood cell count
• C. Albumin level
• D. Hemoglobin level

Correct answer: A

Rationale: Corrected Rationale: In clients with cirrhosis, elevated ammonia levels can lead to hepatic encephalopathy, which is a serious complication. Monitoring ammonia levels is crucial to assess for changes in mental status and initiate treatment if needed. White blood cell count (choice B) is not the most important parameter to monitor in this scenario as it does not directly relate to the complications of cirrhosis. Albumin level (choice C) and hemoglobin level (choice D) are also important in cirrhosis, but in this case, monitoring ammonia level takes precedence due to its direct association with hepatic encephalopathy.

3. The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high-protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective?

• A. A tuna fish sandwich with chips and ice cream
• B. A vegetable salad with croutons and ranch dressing
• C. A grilled chicken breast with steamed vegetables
• D. A peanut butter and jelly sandwich with soda

Correct answer: C

Rationale: The correct answer is C. Grilled chicken is an excellent source of protein, which is important for wound healing. Choices A, B, and D are less ideal for wound healing. Choice A contains high-fat and high-sugar components like chips and ice cream, which may not support wound healing effectively. Choice B includes croutons and ranch dressing, which may not provide as much protein as needed for wound healing. Choice D with a peanut butter and jelly sandwich and soda lacks a balanced meal with adequate protein to promote wound healing.

4. A client with chronic liver disease develops jaundice. What is the most important assessment the nurse should perform?

• A. Assess the client’s skin for lesions or sores.
• B. Monitor the client’s liver function tests.
• C. Assess for changes in mental status and behavior.
• D. Monitor the client’s urine output closely.

Correct answer: D

Rationale: In a client with chronic liver disease developing jaundice, the most important assessment the nurse should perform is to monitor the client’s urine output closely. Jaundice can indicate worsening liver function, so monitoring urine output helps assess kidney function and fluid balance, which are critical in chronic liver disease. Assessing the client’s skin for lesions or sores (Choice A) may be relevant for dermatological conditions but is not the priority in this case. Monitoring liver function tests (Choice B) is important but may not provide immediate information on the client’s current status. Assessing for changes in mental status and behavior (Choice C) is important for detecting hepatic encephalopathy but does not directly address the immediate concern of fluid balance and kidney function in the presence of jaundice.

5. While caring for a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values?

• A. White blood cell count
• B. Hemoglobin
• C. Serum creatinine
• D. Culture for sensitive organisms

Correct answer: D

Rationale: Purulent drainage suggests an infection at the wound site. Reviewing the culture and sensitivity results will guide appropriate antibiotic treatment by identifying the causative organisms and their antibiotic sensitivities. Elevated white blood cells indicate infection but do not specify the organism. Creatinine and hemoglobin values are unrelated to wound infections.

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