Nursing Elites

1. The nurse is caring for a client with cirrhosis of the liver. Which laboratory result requires immediate intervention?

• A. Serum albumin of 3.5 g/dL.
• B. Prothrombin time (PT) of 12 seconds.
• C. Hemoglobin of 10 g/dL.
• D. Serum ammonia level of 180 mcg/dL.

Correct answer: D

Rationale: The correct answer is D, the serum ammonia level of 180 mcg/dL. An elevated serum ammonia level indicates hepatic dysfunction and can lead to hepatic encephalopathy, which is a medical emergency requiring immediate intervention. Options A, B, and C are within normal ranges or slightly abnormal values for clients with cirrhosis and do not pose an immediate threat. Serum albumin levels may indicate malnutrition, prothrombin time may reflect liver synthetic function, and hemoglobin levels can be affected by various factors but do not require immediate intervention in this scenario.

2. A male client who had abdominal surgery has a nasogastric tube for suction, oxygen via nasal cannula, and complains of dry mouth. Which action should the nurse implement?

• A. Apply a petroleum-based lubricant to the lips.
• B. Give sips of water.
• C. Provide ice chips.
• D. Apply a water-soluble lubricant to the lips, oral mucosa, and nares.

Correct answer: D

Rationale: In this scenario, the correct action is to apply a water-soluble lubricant to the lips, oral mucosa, and nares. This helps in keeping the mucous membranes moist, which is essential for a client with a dry mouth due to the nasogastric tube and oxygen therapy. Choice A, applying a petroleum-based lubricant to the lips, is not suitable as it may not be safe for internal use. Choice B, giving sips of water, is contraindicated as the client has a nasogastric tube in place for suction. Choice C, providing ice chips, is also not recommended as the client needs proper lubrication to address dryness, not cold stimulation.

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 client with type 2 diabetes mellitus is admitted with hyperosmolar hyperglycemic state (HHS). Which laboratory result requires immediate intervention?

• A. Serum osmolality of 320 mOsm/kg.
• B. Serum glucose of 600 mg/dL.
• C. Serum potassium of 4.5 mEq/L.
• D. Serum sodium of 140 mEq/L.

Correct answer: B

Rationale: A serum glucose level of 600 mg/dL is extremely high in a client with hyperosmolar hyperglycemic state (HHS) and poses a significant risk of serious complications such as dehydration, coma, and electrolyte imbalances. Rapid intervention is crucial to normalize the glucose level and prevent further deterioration. Serum osmolality of 320 mOsm/kg, serum potassium of 4.5 mEq/L, and serum sodium of 140 mEq/L, while important to monitor in HHS, do not represent an immediate life-threatening condition that requires urgent intervention compared to the critically high glucose level.

5. To prepare a presentation on the greatest health concern facing the city, how should the health nurse begin collecting data?

• A. Review morbidity data for the city's population compiled by the Bureau of Vital Statistics
• B. Conduct a random telephone survey to determine the public's perception about health problems
• C. Survey major hospitals in the area to determine the most common reasons for admissions
• D. Call American Medical Association members to determine the most frequently treated diagnoses

Correct answer: A

Rationale: The correct answer is to review morbidity data for the city's population compiled by the Bureau of Vital Statistics. Morbidity data provides detailed and accurate information on the health issues prevalent in the city's population. This data is essential as it reflects actual health conditions rather than perceptions or specific hospital data. Conducting a telephone survey (choice B) may provide subjective opinions rather than objective data. Surveying hospitals (choice C) may only capture data on hospitalized cases and may not represent the entire population. Contacting American Medical Association members (choice D) may provide insights into medical treatments but may not reflect the overall health concerns of the city's population.

Similar Questions