Nursing Elites

1. A client with a history of chronic heart failure is admitted with shortness of breath. Which assessment finding is most concerning?

• A. Crackles in the lungs
• B. Shortness of breath
• C. Elevated liver enzymes
• D. Heart rate of 100 beats per minute

Correct answer: C

Rationale: Elevated liver enzymes are concerning in a client with chronic heart failure as they may indicate liver congestion or worsening heart failure, requiring immediate intervention. While crackles in the lungs and shortness of breath are common in heart failure, elevated liver enzymes specifically point towards possible liver involvement due to heart failure. A heart rate of 100 beats per minute can be expected in a client with heart failure due to compensatory mechanisms, but elevated liver enzymes signal a more severe condition.

2. A client with liver cirrhosis and ascites is admitted with jaundice. Which laboratory value is most concerning to the nurse?

• A. Serum albumin of 3.0 g/dl
• B. Bilirubin of 3.0 mg/dl
• C. Ammonia level of 80 mcg/dl
• D. Prothrombin time of 18 seconds

Correct answer: C

Rationale: An ammonia level of 80 mcg/dl is elevated and concerning in a client with liver cirrhosis, as it may indicate hepatic encephalopathy. Elevated ammonia levels can lead to neurological symptoms such as confusion, altered mental status, and even coma. Serum albumin, bilirubin, and prothrombin time are important in liver cirrhosis but are not the most concerning for acute neurological deterioration associated with hepatic encephalopathy.

3. A client with cirrhosis is admitted with hepatic encephalopathy. Which clinical finding is most concerning?

• A. Confusion and altered mental status
• B. Increased abdominal girth
• C. Yellowing of the skin
• D. Peripheral edema

Correct answer: A

Rationale: Confusion and altered mental status are the most concerning clinical findings in a client with hepatic encephalopathy. These symptoms indicate worsening liver function and potential neurological complications, requiring immediate medical attention. Increased abdominal girth may suggest ascites, yellowing of the skin can indicate jaundice, and peripheral edema may be related to fluid retention, but in the context of hepatic encephalopathy, confusion and altered mental status take precedence due to the risk of rapid deterioration and the need for prompt management.

4. A client with 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. The use of accessory muscles indicates increased work of breathing and can signal respiratory failure in a client with COPD. This finding requires immediate intervention to prevent further respiratory compromise. Oxygen saturation of 90% indicates some oxygenation impairment but may not necessitate immediate intervention. A respiratory rate of 24 breaths per minute is slightly elevated but does not indicate immediate respiratory distress. Inspiratory crackles may be present in pneumonia but do not require immediate intervention compared to the increased work of breathing indicated by the use of accessory muscles.

5. A female client with ovarian cancer is receiving chemotherapy. Which laboratory result should the nurse report to the healthcare provider immediately?

• A. White blood cell count of 2,000/mm³
• B. Platelet count of 100,000/mm³
• C. Hemoglobin level of 10 g/dL
• D. Serum creatinine level of 1.5 mg/dL

Correct answer: A

Rationale: A white blood cell count of 2,000/mm³ is critically low and places the client at high risk for infection, requiring immediate intervention. Neutropenia, a low white blood cell count, is a common side effect of chemotherapy. A decreased white blood cell count compromises the immune system's ability to fight infections, making it a priority to address to prevent serious complications. Platelet count of 100,000/mm³ is relatively low but not as urgent as a severely low white blood cell count. Hemoglobin level of 10 g/dL is within the normal range for females and does not require immediate intervention. Serum creatinine level of 1.5 mg/dL is also within the normal range and does not pose an immediate threat to the client's health.

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