Nursing Elites

1. A client admitted with a diagnosis of sepsis has a central venous pressure (CVP) of 15 mm Hg. What should the nurse do first?

• A. Administer a fluid bolus of 500 ml.
• B. Notify the healthcare provider immediately.
• C. Administer a diuretic.
• D. Continue to monitor the CVP.

Correct answer: B

Rationale: A CVP of 15 mm Hg is higher than normal, indicating possible fluid overload or heart failure, which needs immediate attention. Notifying the healthcare provider is crucial as they can evaluate the client's condition, order appropriate interventions, and prevent potential complications.

2. In a patient with chronic kidney disease (CKD) receiving erythropoietin therapy, what laboratory result should the nurse monitor to evaluate the effectiveness of this therapy?

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

Correct answer: C

Rationale: The correct answer is C: Hemoglobin level. Erythropoietin therapy is used to stimulate red blood cell production in patients with chronic kidney disease who often develop anemia due to reduced erythropoietin production by the kidneys. Monitoring the hemoglobin level is essential to evaluate the effectiveness of erythropoietin therapy as an increase in hemoglobin indicates improved red blood cell production and better management of anemia in these patients. Serum creatinine, white blood cell count, and serum potassium levels are important parameters to monitor in CKD patients but are not specific indicators of the effectiveness of erythropoietin therapy for managing anemia.

3. The healthcare provider is preparing to administer a blood transfusion. Which action is most important to ensure client safety?

• A. Check the client's vital signs before starting the transfusion.
• B. Verify the client's identity and blood compatibility.
• C. Administer the blood with normal saline.
• D. Monitor the client for the first 15 minutes of the transfusion.

Correct answer: B

Rationale: Verifying the client's identity and blood compatibility is the most critical step in ensuring client safety during a blood transfusion. This process helps prevent transfusion reactions by confirming that the correct blood product is being administered to the right patient.

4. The nurse formulates a nursing diagnosis of 'High risk for ineffective airway clearance' for a client with myasthenia gravis. What is the most likely etiology for this nursing diagnosis?

• A. Pain when coughing.
• B. Diminished cough effort.
• C. Thick, dry secretions.
• D. Excessive inflammation.

Correct answer: B

Rationale: The correct answer is B: Diminished cough effort. Clients with myasthenia gravis often experience muscle weakness, including respiratory muscles, which can lead to diminished cough effort. This weakness can result in ineffective airway clearance, putting the client at a high risk. Pain when coughing (choice A) is not directly related to the etiology of ineffective airway clearance in myasthenia gravis. While thick, dry secretions (choice C) and excessive inflammation (choice D) can contribute to airway clearance issues, the primary concern in myasthenia gravis is the muscle weakness affecting cough effort.

5. In evaluating a 10-year-old child with meningitis suspected of having diabetes insipidus, which finding is indicative of diabetes insipidus?

• A. Decreased urine specific gravity.
• B. Elevated urine glucose.
• C. Decreased serum potassium.
• D. Increased serum sodium.

Correct answer: A

Rationale: Diabetes insipidus is characterized by the kidneys' inability to concentrate urine, leading to decreased urine specific gravity. This results in the excretion of large volumes of dilute urine, causing a decrease in urine specific gravity. Therefore, when evaluating a suspected case of diabetes insipidus, a finding of decreased urine specific gravity is indicative of this condition.

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