Nursing Elites

1. The nurse is assessing a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which laboratory value should the nurse monitor closely?

• A. Serum potassium level
• B. Hemoglobin level
• C. White blood cell count
• D. Serum calcium level

Correct answer: A

Rationale: In a client with chronic kidney disease (CKD) receiving erythropoietin therapy, the nurse should closely monitor the serum potassium level. Erythropoietin therapy can increase red blood cell production, leading to a higher demand for potassium. Monitoring potassium levels is crucial to prevent hyperkalemia, a potential risk associated with this therapy. Hemoglobin level (Choice B) is important to assess the effectiveness of erythropoietin therapy, but monitoring potassium levels takes precedence due to the risk of hyperkalemia. White blood cell count (Choice C) and serum calcium level (Choice D) are not directly affected by erythropoietin therapy in the context of chronic kidney disease.

2. In determining the client position for insertion of an indwelling urinary catheter, it is most important for the nurse to recognize which client condition?

• A. High urinary pH
• B. Abdominal ascites
• C. Orthopnea
• D. Fever

Correct answer: C

Rationale: The correct answer is C: Orthopnea. If the client is orthopneic, the nurse needs to adapt the insertion position that does not place the client in a supine position. This means the head of the bed should be elevated as much as possible to facilitate catheter insertion without compromising the client's breathing. High urinary pH (choice A) is not directly relevant to the insertion position of a urinary catheter. Abdominal ascites (choice B) may impact the procedure due to abdominal distension but is not as crucial as orthopnea. Fever (choice D) does not specifically affect the client's position for urinary catheter insertion.

3. A client with acute pancreatitis is receiving total parenteral nutrition (TPN). Which laboratory value should the nurse monitor closely?

• A. Serum potassium
• B. Serum glucose
• C. Serum triglycerides
• D. Serum calcium

Correct answer: C

Rationale: In a client with acute pancreatitis receiving total parenteral nutrition (TPN), the nurse should monitor serum triglycerides closely. Acute pancreatitis can lead to fat malabsorption, making the client susceptible to hypertriglyceridemia. Monitoring serum triglycerides is crucial to prevent complications such as hyperlipidemia. While monitoring serum potassium, glucose, and calcium levels is also essential in various conditions, in this scenario, the primary concern is the risk of developing hypertriglyceridemia due to fat malabsorption.

4. A 59-year-old male client comes to the clinic and reports his concern over a lump that 'just popped up on my neck about a week ago.' In performing an examination of the lump, the nurse palpates a large, nontender, hardened left subclavian lymph node. There is no overlying tissue inflammation. What do these findings suggest?

• A. Malignancy
• B. Infection
• C. Benign cyst
• D. Lymphadenitis

Correct answer: A

Rationale: The correct answer is A: Malignancy. A large, non-tender, hardened lymph node is a typical sign of malignancy and warrants further investigation. Choice B (Infection) is incorrect because typically in infections, lymph nodes are tender and may show signs of inflammation. Choice C (Benign cyst) is incorrect as a benign cyst would usually present as a soft, mobile lump. Choice D (Lymphadenitis) is incorrect as lymphadenitis usually presents with tender and enlarged lymph nodes due to inflammation.

5. The nurse is assessing the thorax and lungs of a client who is experiencing respiratory difficulty. Which finding is most indicative of respiratory distress?

• A. Contractions of the sternocleidomastoid muscle.
• B. Respiratory rate of 20 breaths/min
• C. Downward movement of diaphragm with inspiration
• D. A pulse oximetry reading of SpO2 95%

Correct answer: A

Rationale: The correct answer is A: Contractions of the sternocleidomastoid muscle. Contractions of the sternocleidomastoid muscle suggest that the client is using accessory muscles to breathe, which is a clear sign of respiratory distress. This finding indicates that the client is working harder to breathe, typically seen in conditions like asthma, COPD, or respiratory failure. Choices B, C, and D are not the most indicative of respiratory distress. A respiratory rate of 20 breaths/min falls within the normal range. Downward movement of the diaphragm with inspiration is a normal finding indicating effective diaphragmatic breathing. A pulse oximetry reading of SpO2 95% is within the normal range and does not necessarily indicate respiratory distress.

Similar Questions