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 client with chronic kidney disease (CKD) is scheduled for a renal biopsy. Which laboratory value should the nurse review before the procedure?

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

Correct answer: B

Rationale: Before a renal biopsy, the nurse should review the serum creatinine level. Serum creatinine is a key indicator of kidney function. In clients with chronic kidney disease (CKD), monitoring creatinine levels is crucial as elevated levels may indicate worsening kidney function, which could impact the safety and outcome of the biopsy. Hemoglobin (choice C) is important for assessing oxygen-carrying capacity but is not directly related to the kidney biopsy procedure. Serum potassium (choice A) is important to monitor in CKD but is not specifically crucial before a renal biopsy. White blood cell count (choice D) is more relevant for assessing infection or inflammation, which is not the primary concern before a renal biopsy.

3. A nurse is caring for a client with Diabetes Insipidus. Which assessment finding warrants immediate intervention by the nurse?

• A. Hypernatremia
• B. Excessive thirst
• C. Elevated heart rate
• D. Poor skin turgor

Correct answer: A

Rationale: The correct answer is A: Hypernatremia. In a client with Diabetes Insipidus, hypernatremia, an elevated sodium level in the blood, can lead to neurological symptoms such as confusion, seizures, or coma. Immediate intervention is necessary to prevent these serious complications. Excessive thirst (choice B) is a common symptom of Diabetes Insipidus but does not require immediate intervention. Elevated heart rate (choice C) and poor skin turgor (choice D) are important assessments but are not as critical as hypernatremia in this context.

4. A client with a history of myocardial infarction is admitted with chest pain. Which laboratory value should the nurse monitor closely?

• A. White blood cell count
• B. Serum creatinine
• C. Troponin level
• D. Hemoglobin level

Correct answer: C

Rationale: The correct answer is C: Troponin level. Troponin levels should be closely monitored in a client with chest pain and a history of myocardial infarction to assess for ongoing myocardial injury. Troponin is a specific marker for myocardial damage. Monitoring white blood cell count (choice A) is not directly related to myocardial infarction. Serum creatinine (choice B) is more indicative of renal function rather than cardiac status. Hemoglobin level (choice D) is important but does not directly reflect ongoing myocardial injury.

5. A client with severe COPD is receiving oxygen therapy at 2 liters per minute via nasal cannula. The client's oxygen saturation level drops to 88% during ambulation. What action should the nurse take first?

• A. Increase the oxygen flow rate to 4 liters per minute.
• B. Instruct the client to rest until the oxygen saturation improves.
• C. Discontinue ambulation and return the client to bed.
• D. Encourage the client to breathe more deeply.

Correct answer: C

Rationale: In this scenario, the client's oxygen saturation level dropping during ambulation indicates an inadequate oxygen supply. The first action the nurse should take is to discontinue ambulation and return the client to bed. This helps stabilize the oxygen level by reducing the oxygen demand placed on the client during physical activity. Increasing the oxygen flow rate without addressing the underlying issue of oxygen saturation dropping may not be effective. Instructing the client to rest is not enough to address the immediate need for stabilization of oxygen levels. Encouraging the client to breathe more deeply may not be sufficient to overcome the oxygen saturation drop caused by inadequate oxygen supply during ambulation.

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