Nursing Elites

1. Which of these findings should the nurse report immediately after a client has a liver biopsy?

• A. Temperature of 99.5 degrees F (37.5 degrees C)
• B. Blood pressure of 108/70
• C. Pulse oximetry reading of 96%
• D. Severe abdominal pain

Correct answer: D

Rationale: The correct answer is D, severe abdominal pain. After a liver biopsy, severe abdominal pain is a critical finding that requires immediate reporting as it may indicate internal bleeding or damage to the liver. The other vital signs provided in choices A, B, and C are within normal limits and may not be directly related to complications post liver biopsy. Therefore, the priority is to address the severe abdominal pain promptly to prevent any further complications.

2. An older client with type 1 diabetes arrives at the clinic with abdominal cramping, vomiting, lethargy, and confusion. What should the nurse implement first?

• A. Start an IV infusion of normal saline.
• B. Obtain a serum potassium level.
• C. Administer the client's usual dose of insulin.
• D. Assess the pupillary response to light.

Correct answer: A

Rationale: The correct answer is A: Start an IV infusion of normal saline. The client is showing signs of dehydration, such as abdominal cramping, vomiting, lethargy, and confusion, which can be exacerbated by hyperglycemia. Rehydration is the initial priority to address the fluid imbalance. Option B, obtaining a serum potassium level, though important in the management of diabetes, is not the immediate priority over rehydration. Option C, administering the client's usual dose of insulin, should only be done after addressing the dehydration and confirming the client's blood glucose levels. Option D, assessing the pupillary response to light, is not the most urgent intervention needed in this situation compared to rehydration to correct fluid imbalance.

3. A client with a history of stroke is receiving warfarin. What is the nurse's priority assessment?

• A. Check the client's blood pressure.
• B. Assess for signs of bleeding.
• C. Assess the client's neurological status.
• D. Monitor the client's intake and output.

Correct answer: B

Rationale: The correct answer is to assess for signs of bleeding. Warfarin is an anticoagulant that increases the risk of bleeding in patients. Monitoring for signs of bleeding such as easy bruising, petechiae, blood in urine or stool, or unusual bleeding from gums is crucial. Checking the client's blood pressure (choice A) is important but not the priority in this situation. Assessing the client's neurological status (choice C) is essential in stroke patients but is not the priority related to warfarin therapy. Monitoring intake and output (choice D) is important for overall assessment but is not the priority when a client is on warfarin, as assessing for bleeding takes precedence.

4. After receiving a report on an inpatient acute care unit, which client should the nurse assess first?

• A. Client with pneumonia who has a fever of 101.5°F
• B. Client who underwent knee surgery and needs dressing change
• C. Client with a bowel obstruction due to a volvulus experiencing abdominal rigidity
• D. Client with diabetes requesting insulin

Correct answer: C

Rationale: The correct answer is C. Abdominal rigidity in a client with a bowel obstruction could indicate peritonitis, a serious complication requiring immediate attention. Volvulus, a twisting of the intestine, can lead to bowel ischemia and necrosis. Clients with pneumonia (choice A) may need assessment and treatment for infection, but it is not as immediately life-threatening as a bowel obstruction. A client who underwent knee surgery (choice B) needing a dressing change can typically wait for assessment compared to a potential surgical emergency. Similarly, a client with diabetes requesting insulin (choice D) may require attention to maintain blood glucose levels, but it is not as urgent as a suspected bowel obstruction with possible peritonitis.

5. Which of these findings would the nurse more closely associate with anemia in a 10-month-old infant?

• A. Hemoglobin level of 12 g/dL
• B. Pale mucosa of the eyelids and lips
• C. Hypoactivity
• D. A heart rate between 140 to 160

Correct answer: B

Rationale: The correct answer is B. Pale mucous membranes, such as those of the eyelids and lips, are a classic sign of anemia in infants. Anemia leads to decreased oxygen-carrying capacity, resulting in tissue hypoxia, which can manifest as pale mucosa. Choice A, a hemoglobin level of 12 g/dL, is within the normal range for a 10-month-old infant and would not necessarily indicate anemia. Choice C, hypoactivity, is a non-specific finding and can be present in various conditions, not specifically anemia. Choice D, a heart rate between 140 to 160, is within the normal range for an infant and is not a specific finding associated with anemia.

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