Nursing Elites

1. Which assessment finding requires immediate intervention for a client receiving enteral feedings via a nasogastric tube?

• A. Auscultate the client's lungs for breath sounds
• B. Check the client's blood glucose level
• C. Monitor the client's bowel sounds
• D. Elevate the head of the bed to 45 degrees

Correct answer: D

Rationale: Elevating the head of the bed to 45 degrees is crucial for clients receiving enteral feedings via a nasogastric tube to prevent aspiration. Aspiration can lead to serious complications such as pneumonia. Auscultating the client's lungs for breath sounds (choice A) is important but not as urgent as preventing aspiration. Checking the client's blood glucose level (choice B) and monitoring bowel sounds (choice C) are also essential aspects of care for a client receiving enteral feedings, but they do not take precedence over preventing aspiration.

2. A client with chronic kidney disease (CKD) is admitted with hyperkalemia. Which laboratory value is most concerning?

• A. Serum potassium of 6.5 mEq/L
• B. Serum sodium of 135 mEq/L
• C. Serum creatinine of 2.0 mg/dl
• D. Blood glucose of 150 mg/dl

Correct answer: A

Rationale: A serum potassium level of 6.5 mEq/L is concerning in a client with CKD as it indicates hyperkalemia, which requires immediate intervention to prevent cardiac complications. Hyperkalemia can lead to life-threatening arrhythmias, particularly in patients with impaired kidney function. Serum sodium, creatinine, and blood glucose levels, while important, are not as acutely dangerous as severe hyperkalemia in this context.

3. A female client with breast cancer who completed her first chemotherapy treatment today at an outpatient center is preparing for discharge. Which behavior indicates that the client understands her care needs?

• A. Rented movies and borrowed books to use while passing time at home
• B. Made an appointment with the oncologist for follow-up treatment
• C. Expressed concern about hair loss and fatigue
• D. Asked for dietary recommendations to manage nausea

Correct answer: A

Rationale: Choice A is the correct answer. Renting movies and borrowing books to use at home indicate that the client understands the need for rest and self-care after chemotherapy. This behavior demonstrates the client's intention to engage in activities that promote relaxation and recovery. Choices B, C, and D are incorrect because making an appointment for follow-up treatment, expressing concern about side effects like hair loss and fatigue, and asking for dietary recommendations are important but do not directly reflect the client's understanding of her immediate care needs post-chemotherapy.

4. A client with type 2 diabetes is admitted with hyperglycemic hyperosmolar syndrome (HHS). Which laboratory value requires immediate intervention?

• A. Serum glucose of 600 mg/dL
• B. Serum osmolarity of 320 mOsm/kg
• C. Serum sodium of 130 mEq/L
• D. Serum potassium of 5.0 mEq/L

Correct answer: B

Rationale: A serum osmolarity of 320 mOsm/kg is concerning in a client with HHS because it indicates severe dehydration and hyperosmolarity, which requires immediate intervention. In HHS, the elevated serum osmolarity leads to neurological symptoms and can result in serious complications if not addressed promptly. While a high serum glucose level (choice A) is typical in HHS, the osmolarity is a more direct indicator of dehydration and severity. Serum sodium (choice C) and potassium levels (choice D) are important but do not pose an immediate threat to the client's condition compared to the severe hyperosmolarity indicated by a high serum osmolarity level.

5. A male client is having abdominal pain after a left femoral angioplasty and stent, and is asking for additional pain medication for right lower quadrant pain (9/10). Two hours ago, he received hydrocodone/acetaminophen 7.5/7.50 mg. His vital signs are elevated from the previous hour: temperature 97.8 F, heart rate 102 beats per minute, respiration 20 breaths per minute. His abdomen is swollen, the groin access site is tender, peripheral pulses are present, but the left leg is larger than the right. Preoperatively, clopidogrel was prescribed for a history of previous peripheral stents. Another nurse is holding manual pressure on the femoral arterial access site which may be leaking into the abdomen. What data is needed to make this report complete?

• A. Client's lungs are clear bilaterally, and oxygen saturation is 97%.
• B. The surgeon needs to see the client immediately to evaluate the situation.
• C. Left peripheral pulses were present only by Doppler pre-procedure.
• D. Client's history includes multiple back surgeries and chronic pain.

Correct answer: B

Rationale: The correct answer is B. Immediate evaluation by the surgeon is necessary due to the possibility of an internal hemorrhage, which is a life-threatening condition. Choice A is incorrect as lung status and oxygen saturation are not the priority in this situation. Choice C is not relevant to the current urgent issue. Choice D, while providing additional history, is not pertinent to the immediate concern of a potential internal hemorrhage post angioplasty and stent placement.

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