Nursing Elites

1. The healthcare provider is assessing a client who has returned from hemodialysis. Which finding requires immediate intervention?

• A. Weight gain of 1 pound.
• B. Dizziness.
• C. Fatigue.
• D. Muscle cramps.

Correct answer: D

Rationale: After hemodialysis, muscle cramps can indicate an electrolyte imbalance, such as low potassium or magnesium levels, which requires immediate intervention to prevent potential complications like cardiac arrhythmias. Weight gain of 1 pound, dizziness, and fatigue are common post-hemodialysis symptoms that may not necessarily require immediate intervention unless they are severe or persisting.

2. A client with a history of alcohol abuse is admitted with acute pancreatitis. Which laboratory result requires immediate intervention?

• A. Amylase of 120 U/L.
• B. Lipase of 150 U/L.
• C. Calcium of 8.5 mg/dL.
• D. Blood glucose of 250 mg/dL.

Correct answer: D

Rationale: The correct answer is D, 'Blood glucose of 250 mg/dL.' In a client with acute pancreatitis, elevated blood glucose levels can indicate poor control of diabetes or stress response from the acute illness. Immediate intervention is necessary to prevent complications like worsening pancreatitis, infections, or other metabolic issues. Choices A and B, 'Amylase of 120 U/L' and 'Lipase of 150 U/L,' are commonly elevated in pancreatitis but do not require immediate intervention unless significantly elevated. Choice C, 'Calcium of 8.5 mg/dL,' is within the normal range and not a priority in this scenario.

3. The healthcare provider is preparing to administer digoxin (Lanoxin) to a client. Which assessment finding should the healthcare provider report before administering the medication?

• A. Apical pulse of 58 beats per minute.
• B. Serum potassium level of 3.0 mEq/L.
• C. Blood pressure of 140/90 mm Hg.
• D. Client reports seeing halos around lights.

Correct answer: D

Rationale: Seeing halos around lights is a classic symptom of digoxin toxicity, known as visual disturbances. This finding indicates an adverse effect of digoxin and should be reported immediately to the healthcare provider. Monitoring for visual changes is crucial as it can progress to more severe toxicity, leading to life-threatening dysrhythmias or other complications. Apical pulse, serum potassium level, and blood pressure are important assessments when administering digoxin, but the presence of visual disturbances, such as seeing halos around lights, takes precedence due to its direct association with digoxin toxicity. Changes in these other parameters should also be noted and addressed, but they are not the priority when compared to a symptom directly linked to potential toxicity.

4. A school nurse is developing a health risk screening protocol for use at an elementary school. What information is most important for the nurse to include in this protocol?

• A. annual flu vaccination status
• B. weight and height measurement
• C. total cholesterol level
• D. long bone deformity testing

Correct answer: B

Rationale: Weight and height measurements are crucial components of health screenings in children as they help assess growth patterns and identify potential health concerns such as obesity or growth disorders. Monitoring weight and height regularly can aid in early intervention and prevention of health issues. Annual flu vaccination status, total cholesterol level, and long bone deformity testing are not typically primary components of routine health screenings in elementary school children and may not directly contribute to identifying common health risks in this population.

5. An adolescent tells the school nurse that she is pregnant. Her last menstrual period was 4 months ago. She has not received any medical care. She smokes but denies any other substance use. What is the priority nursing action?

• A. notify her parents
• B. refer her for prenatal care
• C. teach breastfeeding methods
• D. offer nutritional instructions

Correct answer: B

Rationale: The correct answer is to refer her for prenatal care. Prenatal care is essential to monitor the health of both the mother and the fetus during pregnancy. While notifying her parents may be important for support and involvement, the priority is ensuring the adolescent receives medical care. Teaching breastfeeding methods and offering nutritional instructions are important but are not the immediate priority in this situation where prenatal care is urgently needed.

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