Nursing Elites

1. A client with a history of atrial fibrillation is prescribed warfarin (Coumadin). Which clinical finding is most concerning?

• A. Headache
• B. Prothrombin time (PT) of 15 seconds
• C. Elevated liver enzymes
• D. Peripheral edema

Correct answer: A

Rationale: The correct answer is A: Headache. In a client with atrial fibrillation taking warfarin (Coumadin), a headache can be indicative of bleeding, which is a serious complication requiring immediate assessment and intervention. Monitoring for signs of bleeding is crucial when on anticoagulant therapy. Choices B, C, and D are not the most concerning. A prothrombin time of 15 seconds is within the therapeutic range for a client on warfarin, elevated liver enzymes may indicate liver dysfunction but are not directly related to the medication's side effects, and peripheral edema is not typically associated with warfarin use or atrial fibrillation in this context.

2. A client with type 1 diabetes is admitted with diabetic ketoacidosis (DKA). Which laboratory value is most concerning?

• A. Serum glucose of 300 mg/dl
• B. Serum bicarbonate of 18 mEq/L
• C. Serum potassium of 5.5 mEq/L
• D. Serum sodium of 135 mEq/L

Correct answer: C

Rationale: A serum potassium level of 5.5 mEq/L is concerning in a client with DKA as it may indicate worsening hyperkalemia, requiring immediate intervention. Elevated serum potassium levels can lead to life-threatening cardiac arrhythmias. While elevated glucose and low bicarbonate are characteristic of DKA, hyperkalemia poses a higher immediate risk. Serum sodium within the normal range is not typically a primary concern in DKA.

3. The nurse is caring for a client with a history of myocardial infarction who is experiencing chest pain. Which diagnostic test should the nurse anticipate preparing the client for first?

• A. Electrocardiogram (ECG)
• B. Chest X-ray
• C. Arterial blood gases (ABGs)
• D. Echocardiogram

Correct answer: A

Rationale: Corrected Rationale: An electrocardiogram (ECG) should be performed first to assess for cardiac ischemia in a client with a history of myocardial infarction and chest pain. An ECG provides immediate information about the heart's electrical activity, helping to identify changes indicative of cardiac ischemia or infarction. Chest X-ray (Choice B) is not the initial diagnostic test for assessing chest pain related to myocardial infarction. Arterial blood gases (Choice C) are used to assess oxygenation and acid-base balance but are not the primary diagnostic test for myocardial infarction. An echocardiogram (Choice D) may provide valuable information about cardiac structure and function, but it is not the first-line diagnostic test for acute chest pain in a client with a history of myocardial infarction.

4. A 10-year-old who has terminal brain cancer asks the nurse, 'What will happen to my body when I die?' How should the nurse respond?

• A. Your mother and father will be here soon. Talk to them about that.'
• B. Why do you want to know about what will happen to your body when you die?'
• C. The heart will stop beating and you will stop breathing.'
• D. Are you concerned about where your spirit will go?'

Correct answer: C

Rationale: The correct response when a terminally ill child asks about what will happen to their body when they die is to provide a truthful and straightforward answer. Choice C, 'The heart will stop beating and you will stop breathing,' is the best response because it offers a simple and honest explanation without delving into spiritual or emotional aspects that may be confusing or distressing to the child. Choices A and D deflect the question and do not address the child's inquiry directly. Choice B, 'Why do you want to know about what will happen to your body when you die?' may come across as dismissive or evasive, rather than providing the clear information the child is seeking.

5. A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Which assessment finding requires immediate intervention?

• A. Oxygen saturation of 90%
• B. Respiratory rate of 24 breaths per minute
• C. Use of accessory muscles
• D. Inspiratory crackles

Correct answer: C

Rationale: The correct answer is C: Use of accessory muscles. In a client with COPD and pneumonia, the use of accessory muscles indicates increased work of breathing and may signal respiratory failure. Immediate intervention is necessary to prevent further deterioration of the respiratory status. Choice A, an oxygen saturation of 90%, though low, may not require immediate intervention as it is above the typical threshold for initiating supplemental oxygen. Choice B, a respiratory rate of 24 breaths per minute, falls within the normal range for an adult and may not be an immediate cause for concern. Choice D, inspiratory crackles, are indicative of fluid in the lungs but may not require immediate intervention unless accompanied by other concerning signs like decreased oxygen saturation or increased respiratory distress.

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