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. The nurse is caring for a client with chronic kidney disease (CKD). Which laboratory value should be reported to the healthcare provider immediately?

• A. Serum creatinine of 2.0 mg/dl
• B. Hemoglobin of 10 g/dl
• C. Potassium of 6.5 mEq/L
• D. Blood glucose of 150 mg/dl

Correct answer: C

Rationale: The correct answer is C. A potassium level of 6.5 mEq/L is dangerously high, a condition known as hyperkalemia, and requires immediate intervention to prevent cardiac complications. Hyperkalemia can lead to life-threatening arrhythmias, making it crucial to notify the healthcare provider promptly. Choices A, B, and D do not indicate immediate life-threatening conditions. Elevated serum creatinine levels are expected in CKD, a hemoglobin level of 10 g/dl is within a reasonable range, and a blood glucose level of 150 mg/dl is not acutely concerning in this context.

3. When finding a client sitting on the floor, the nurse calls for help from the unlicensed assistive personnel (UAP). Which task should the nurse ask the UAP to do?

• A. Check for any abrasions or bruises.
• B. Help the client to stand.
• C. Get a blood pressure cuff.
• D. Report the fall to the nurse-manager.

Correct answer: C

Rationale: The correct task for the nurse to ask the unlicensed assistive personnel (UAP) to do in this situation is to "Get a blood pressure cuff." This is important because assessing the client's vital signs, including blood pressure, is crucial after a fall to ensure there are no underlying issues like hypotension. Choices A and B may be important tasks for the nurse to perform as part of the assessment and care of the client. However, in this scenario, the immediate concern should be to check the client's blood pressure. Choice D is not the most urgent task at this time, as assessing the client's condition takes precedence.

4. The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client's plan of care?

• A. Record urine output every hour
• B. Monitor blood pressure frequently
• C. Evaluate neurological status
• D. Maintain seizure precautions

Correct answer: B

Rationale: Monitoring blood pressure frequently is the highest priority intervention for a client diagnosed with pheochromocytoma. This rare tumor can lead to life-threatening hypertension due to catecholamine secretion. Evaluating neurological status and maintaining seizure precautions are important but are not the highest priority in this case. Recording urine output, though essential for overall assessment, is not the priority compared to monitoring blood pressure in a client with pheochromocytoma.

5. A client with a history of atrial fibrillation is admitted with a new onset of confusion. Which laboratory value should the nurse monitor closely?

• A. International Normalized Ratio (INR)
• B. Serum glucose level
• C. White blood cell count
• D. Prothrombin time (PT)

Correct answer: A

Rationale: The correct answer is A: International Normalized Ratio (INR). The INR should be closely monitored in a client with atrial fibrillation to assess the effectiveness and safety of anticoagulation therapy with warfarin. Monitoring the INR helps to ensure that the client is within the therapeutic range to prevent complications such as thrombosis or bleeding. Choices B, C, and D are less relevant in this scenario. While serum glucose levels are important in assessing metabolic status, and white blood cell count and prothrombin time are important indicators for other conditions, they are not the primary focus when a client with atrial fibrillation presents with confusion.

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