Nursing Elites

1. The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine, and the UAP is placing soft pillows along the side rails. What action should the nurse take?

• A. Ensure that the UAP has positioned the pillows effectively to protect the client.
• B. Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows.
• C. Assume responsibility for placing the pillows while the UAP completes another task.
• D. Ask the UAP to use some of the pillows to prop the client in a side-lying position.

Correct answer: B

Rationale: The nurse should instruct the UAP to pad the side rails with soft blankets instead of pillows. Placing pillows along the side rails could lead to suffocation during a seizure and would need to be removed promptly. Instructing the UAP to use soft blankets is safer as they can help prevent injury without posing a risk of suffocation. Ensuring effective placement of the pillows (Choice A) is not appropriate as pillows should not be used in this situation. Assuming responsibility for placing the pillows (Choice C) or propping the client in a side-lying position with pillows (Choice D) are both unsafe actions and could potentially harm the client.

2. A female client with major depressive disorder tells the nurse she feels worthless and can't see how her life will ever get better. What is the best response by the nurse?

• A. I can understand how you feel. Tell me more about what's been going on.
• B. You're going through a tough time. Let's discuss what makes you feel this way.
• C. You sound very hopeless right now. Are you thinking about harming yourself?
• D. It's difficult to see the light when you're feeling this way, but I'm here to help you.

Correct answer: C

Rationale: Choice C is the best response because it directly addresses the client's expressed hopelessness and assesses the risk for self-harm. When a client with major depressive disorder expresses feeling worthless and unable to see improvement, it is essential to assess suicidal ideation to ensure their safety. Choices A, B, and D provide empathy and support, which are important but addressing suicidal ideation is the priority in this situation.

3. A client with a history of chronic kidney disease (CKD) is receiving erythropoietin therapy. Which assessment finding is most concerning?

• A. Increased fatigue
• B. Headache
• C. Elevated blood pressure
• D. Low urine output

Correct answer: C

Rationale: In a client with chronic kidney disease receiving erythropoietin therapy, elevated blood pressure is the most concerning assessment finding. Erythropoietin can increase red blood cell production, leading to thicker blood, which in turn can elevate blood pressure. Elevated blood pressure in this scenario may indicate worsening hypertension, which requires prompt intervention to prevent complications such as stroke, heart attack, or further kidney damage. Increased fatigue (choice A) is a common symptom in CKD patients and can be expected with erythropoietin therapy. Headache (choice B) can occur but is less concerning than elevated blood pressure in this context. Low urine output (choice D) is a significant finding in CKD, but in a client receiving erythropoietin, elevated blood pressure takes precedence due to its potential for immediate adverse effects.

4. The client with chronic obstructive pulmonary disease (COPD) is receiving supplemental oxygen. Which laboratory value is most concerning?

• A. Serum sodium of 135 mEq/L
• B. Serum potassium of 4.0 mEq/L
• C. Serum bicarbonate of 18 mEq/L
• D. Serum glucose of 300 mg/dl

Correct answer: C

Rationale: A serum bicarbonate level of 18 mEq/L is concerning in a client with COPD receiving supplemental oxygen as it indicates metabolic acidosis, which can occur due to the body compensating for chronic respiratory acidosis. This condition requires immediate intervention to restore the acid-base balance. Choice A, serum sodium of 135 mEq/L, is within normal range (135-145 mEq/L) and not directly related to COPD or oxygen therapy. Choice B, serum potassium of 4.0 mEq/L, falls within the normal range (3.5-5.0 mEq/L) and is not typically affected by COPD or oxygen therapy. Choice D, serum glucose of 300 mg/dl, though elevated, is not directly related to COPD or oxygen therapy and would require management but is not the most concerning value in this scenario.

5. A client is admitted with a possible myocardial infarction. Which laboratory test result is most indicative of a myocardial infarction?

• A. Serum creatine kinase (CK)
• B. Serum troponin
• C. Serum myoglobin
• D. C-reactive protein (CRP)

Correct answer: B

Rationale: Serum troponin is the most specific and sensitive indicator of myocardial infarction. Troponin levels rise within 3-4 hours after myocardial damage, peak at 10-24 hours, and remain elevated for up to 10-14 days. Creatine kinase (CK) and myoglobin can also be elevated in myocardial infarction, but troponin is more specific to cardiac muscle damage. C-reactive protein (CRP) is a marker of inflammation and is not specific for myocardial infarction.

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