Nursing Elites

1. A client with chronic liver disease develops jaundice. What is the most important assessment the nurse should perform?

• A. Assess the client’s skin for lesions or sores.
• B. Monitor the client’s liver function tests.
• C. Assess for changes in mental status and behavior.
• D. Monitor the client’s urine output closely.

Correct answer: D

Rationale: In a client with chronic liver disease developing jaundice, the most important assessment the nurse should perform is to monitor the client’s urine output closely. Jaundice can indicate worsening liver function, so monitoring urine output helps assess kidney function and fluid balance, which are critical in chronic liver disease. Assessing the client’s skin for lesions or sores (Choice A) may be relevant for dermatological conditions but is not the priority in this case. Monitoring liver function tests (Choice B) is important but may not provide immediate information on the client’s current status. Assessing for changes in mental status and behavior (Choice C) is important for detecting hepatic encephalopathy but does not directly address the immediate concern of fluid balance and kidney function in the presence of jaundice.

2. The nurse is providing care for a client with suspected deep vein thrombosis (DVT) in the left leg. Which action should the nurse take first?

• A. Encourage the client to ambulate
• B. Apply a warm compress to the left leg
• C. Elevate the client's left leg
• D. Administer a prescribed anticoagulant

Correct answer: C

Rationale: Elevating the affected leg promotes venous return and reduces swelling, which is a priority intervention for a client with suspected DVT. This action helps prevent the thrombus from dislodging and causing further complications. Encouraging ambulation may dislodge the clot, leading to a pulmonary embolism. Applying a warm compress can increase blood flow to the area, potentially dislodging the clot. Administering anticoagulants is essential but should not be the first action as elevation helps to reduce the risk of complications associated with DVT.

3. A client receiving IV antibiotics for sepsis reports itching and has a rash on the chest. What is the nurse's first action?

• A. Administer an antihistamine as prescribed.
• B. Stop the infusion and notify the healthcare provider.
• C. Slow the infusion rate and monitor the client.
• D. Administer epinephrine subcutaneously.

Correct answer: B

Rationale: The correct action for the nurse to take first when a client receiving IV antibiotics for sepsis reports itching and a rash on the chest is to stop the infusion and notify the healthcare provider. This is crucial in preventing the allergic reaction from worsening. Administering an antihistamine (choice A) may address the symptoms but does not address the primary concern of stopping the infusion. Slowing the infusion rate and monitoring the client (choice C) may not be sufficient if the reaction is severe. Administering epinephrine subcutaneously (choice D) is not the first-line intervention for this situation.

4. Prior to administering warfarin to a client with a history of atrial fibrillation, what lab result should the nurse review?

• A. White blood cell count.
• B. Prothrombin time (PT) and International Normalized Ratio (INR).
• C. Hemoglobin and hematocrit.
• D. Blood urea nitrogen (BUN) and creatinine.

Correct answer: B

Rationale: The correct answer is B: Prothrombin time (PT) and International Normalized Ratio (INR). These lab values are crucial for monitoring the effectiveness of warfarin, an anticoagulant medication. PT measures the time it takes for blood to clot, while INR standardizes these results. Ensuring the client's PT/INR levels are within the therapeutic range is essential to prevent clotting or excessive bleeding. Choices A, C, and D are incorrect as they are not directly related to monitoring warfarin therapy in a client with atrial fibrillation.

5. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who has been experiencing increasing shortness of breath. Which finding requires immediate intervention?

• A. A respiratory rate of 26 breaths per minute
• B. Use of accessory muscles for breathing
• C. Barrel chest appearance
• D. A pulse oximetry reading of 88%

Correct answer: D

Rationale: A pulse oximetry reading of 88% indicates hypoxemia, which requires immediate intervention to improve oxygenation. Hypoxemia can lead to serious complications if not addressed promptly. While a respiratory rate of 26 breaths per minute and the use of accessory muscles for breathing are concerning in COPD, they do not indicate an immediate life-threatening situation. Similarly, a barrel chest appearance is a common finding in COPD and does not require urgent intervention compared to the critical need to address hypoxemia.

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