Nursing Elites

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

• A. Barrel-shaped chest
• B. Use of accessory muscles
• C. Oxygen saturation of 85%
• D. Inspiratory crackles

Correct answer: C

Rationale: An oxygen saturation of 85% is significantly low for a client with COPD and requires immediate intervention to prevent hypoxemia. Oxygen saturation below 90% indicates poor oxygenation and poses a risk of tissue hypoxia, making it a critical finding that needs prompt attention. Barrel-shaped chest and inspiratory crackles are commonly seen in clients with COPD and do not necessitate immediate intervention. The use of accessory muscles may indicate increased work of breathing but does not pose the same level of immediate threat as severe hypoxemia.

2. A client with rheumatoid arthritis is scheduled to receive a dose of methotrexate. Which laboratory result is most important for the nurse to review before administering the medication?

• A. White blood cell count
• B. Liver function tests
• C. Kidney function tests
• D. Complete blood count

Correct answer: B

Rationale: The correct answer is B: Liver function tests. Before administering methotrexate, it is crucial to review liver function tests due to the medication's potential hepatotoxic effects. Methotrexate can cause liver damage, so monitoring liver function is essential to prevent any serious complications. While white blood cell count, kidney function tests, and complete blood count are important parameters to monitor in certain situations, they are not the most critical before administering methotrexate.

3. The nurse is triaging several children as they present to the emergency room after an accident. Which child requires the most immediate intervention by the nurse?

• A. An 11-year-old with a headache, nausea, and projectile vomiting
• B. A 5-year-old with a broken arm
• C. A 7-year-old with minor abrasions
• D. A 9-year-old with a twisted ankle

Correct answer: A

Rationale: The correct answer is A. Projectile vomiting in a child with a headache could indicate increased intracranial pressure, requiring immediate attention. Choices B, C, and D do not present with symptoms indicating potentially life-threatening conditions that require urgent intervention.

4. A client with chronic kidney disease (CKD) is receiving erythropoietin therapy. Which laboratory value should the nurse monitor closely?

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

Correct answer: A

Rationale: The correct answer is A: Serum potassium. When a client with chronic kidney disease is receiving erythropoietin therapy, monitoring serum potassium closely is essential. Erythropoietin therapy can lead to increased red blood cell production, which may cause potassium levels to rise, potentially resulting in hyperkalemia. Monitoring potassium levels helps prevent complications associated with hyperkalemia. Choices B, C, and D are incorrect because they are not directly impacted by erythropoietin therapy in the context of CKD.

5. Following an open reduction of the tibia, the nurse notes bleeding on the client's cast. Which action should the nurse implement?

• A. Outline the area with ink and check it every 15 minutes to see if the area has increased
• B. Notify the healthcare provider immediately
• C. Apply a new cast to stop the bleeding
• D. Elevate the limb to reduce blood flow

Correct answer: A

Rationale: After an open reduction of the tibia, bleeding on the cast can be a concern. Outlining the area with ink and monitoring it every 15 minutes is the appropriate action to assess if the bleeding is worsening, indicating the need for further intervention. This action allows for close observation without disturbing the cast. Choice B is incorrect because while notifying the healthcare provider is important, immediate action is not always necessary if the bleeding is not severe. Choice C is incorrect because applying a new cast is not the standard intervention for bleeding on a cast. Choice D is incorrect because elevating the limb may not address the underlying cause of bleeding and may not be the most appropriate action at this time.

Similar Questions