Nursing Elites

1. A client receiving chemotherapy has severe neutropenia. What snack is best for the nurse to recommend?

• A. Baked apples with raisins.
• B. Yogurt with fresh berries.
• C. Avocados and cheese.
• D. Fresh fruit salad.

Correct answer: B

Rationale: For a client with severe neutropenia, it is crucial to recommend a snack that is low in bacteria to reduce the risk of infection. Yogurt with fresh berries is an excellent choice as it is not only low in bacteria but also provides nutritional value. Baked apples with raisins (choice A) may not be ideal as the preparation process could introduce bacteria. Avocados and cheese (choice C) may not be the best option due to their potential bacterial content. Fresh fruit salad (choice D) may have a higher risk of bacterial contamination compared to yogurt with fresh berries.

2. A client with myasthenia gravis (MG) is receiving immunosuppressive therapy. Recent lab tests show decreased serum magnesium. What nursing action is most important?

• A. Observe rhythm on telemetry monitor.
• B. Check for visual difficulties.
• C. Assess for hip and hand joint pain.
• D. Note the most recent hemoglobin level.

Correct answer: A

Rationale: Magnesium plays a crucial role in maintaining normal cardiac rhythms, particularly in patients with cardiac conditions. Abnormal levels can lead to arrhythmias, which is why continuous monitoring of the heart's electrical activity is important. Magnesium's effect on neuromuscular and cardiac function makes it essential to monitor its levels, and any discrepancies can impact treatment decisions. Checking for visual difficulties (choice B) may be important in MG but is not the priority in the context of decreased serum magnesium. Assessing for hip and hand joint pain (choice C) is not directly related to the issue of decreased serum magnesium. Noting the most recent hemoglobin level (choice D) is not the priority in this situation compared to monitoring the cardiac rhythm due to low magnesium levels.

3. A client with cirrhosis is receiving lactulose. What is the most important assessment for the nurse to monitor?

• A. Monitor the client's ammonia levels.
• B. Monitor the client's blood glucose level.
• C. Monitor the client's potassium levels.
• D. Monitor the client's level of consciousness.

Correct answer: D

Rationale: The correct answer is to monitor the client's level of consciousness. Lactulose is used to reduce ammonia levels in hepatic encephalopathy. Monitoring the level of consciousness helps assess the effectiveness of lactulose therapy in improving the client's condition. Monitoring ammonia levels (choice A) is important, but assessing the client's response to therapy through their level of consciousness is more crucial. Blood glucose levels (choice B) and potassium levels (choice C) are not directly related to lactulose therapy for cirrhosis and hepatic encephalopathy.

4. A client with chronic kidney disease is prescribed erythropoietin. What is the nurse's priority action?

• A. Monitor the client's hemoglobin and hematocrit.
• B. Monitor the client's blood pressure.
• C. Assess the client for signs of infection.
• D. Monitor the client for signs of bleeding.

Correct answer: A

Rationale: The correct answer is A: 'Monitor the client's hemoglobin and hematocrit.' When a client with chronic kidney disease is prescribed erythropoietin, the nurse's priority action is to monitor the client's hemoglobin and hematocrit. Erythropoietin stimulates red blood cell production, so monitoring these lab values helps evaluate the effectiveness of erythropoietin in treating anemia. Monitoring the client's blood pressure (choice B) is important but not the priority in this scenario. Assessing the client for signs of infection (choice C) is important but not the priority related to the prescription of erythropoietin. Monitoring the client for signs of bleeding (choice D) is relevant but not the priority action when erythropoietin is prescribed.

5. A client with heart failure is experiencing shortness of breath and swelling in the legs. What is the nurse's priority intervention?

• A. Administer prescribed diuretics
• B. Place the client in a supine position
• C. Restrict fluid intake immediately
• D. Increase the client's sodium intake

Correct answer: A

Rationale: The correct answer is A: Administer prescribed diuretics. Diuretics are prescribed to reduce fluid overload in clients with heart failure. By promoting urine output, diuretics help alleviate symptoms like shortness of breath and swelling. While placing the client in a supine position can help with breathing and fluid redistribution, administering diuretics takes precedence as it directly addresses fluid overload. Restricting fluid intake immediately may be necessary in some cases, but the immediate priority is to administer diuretics. Increasing the client's sodium intake would worsen fluid retention and is contraindicated in heart failure.

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