Nursing Elites

1. 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.

2. A male client with hypertension, who received new antihypertensive prescriptions at his last visit, returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106, and he admits that he has not been taking the prescribed medication because the drugs make him 'feel bad'. In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition?

• A. Blindness due to cataracts
• B. Acute kidney injury due to glomerular damage
• C. Stroke secondary to hemorrhage
• D. Heart block due to myocardial damage

Correct answer: C

Rationale: The correct answer is C, 'Stroke secondary to hemorrhage.' Uncontrolled hypertension can lead to the weakening of blood vessels in the brain, increasing the risk of a stroke due to hemorrhage. This can result in serious neurological deficits or even death. Choices A, B, and D are incorrect because while hypertension can have various complications including vision changes, kidney damage, and heart problems, the most immediate and severe risk associated with uncontrolled hypertension is a stroke from cerebral hemorrhage.

3. What is the most important instruction for the nurse to provide a client being discharged following treatment for Guillain-Barre syndrome?

• A. Avoid exposure to respiratory infections.
• B. Use relaxation exercises when anxious.
• C. Continue physical therapy at home.
• D. Plan short, frequent rest periods.

Correct answer: A

Rationale: The most critical instruction for a client being discharged following treatment for Guillain-Barre syndrome is to avoid exposure to respiratory infections. Guillain-Barre syndrome can affect the respiratory system, making infections particularly dangerous. While relaxation exercises, physical therapy, and rest periods are beneficial for overall well-being and recovery, preventing respiratory infections takes precedence due to the potential life-threatening complications associated with respiratory compromise in Guillain-Barre syndrome.

4. The nurse is assessing a client with a small bowel obstruction who was hospitalized 24 hours ago. Which assessment finding should the nurse report immediately to the healthcare provider?

• A. Hypoactive bowel sounds in the lower quadrant.
• B. Rebound tenderness in the upper quadrants.
• C. Tympany with percussion of the abdomen.
• D. Light-colored gastric aspirate via the nasogastric tube.

Correct answer: B

Rationale: Rebound tenderness in the upper quadrants may indicate peritonitis, which requires prompt medical attention. Hypoactive bowel sounds are expected in small bowel obstruction and would not be a priority over signs of peritonitis. Tympany with percussion is a normal finding and not a cause for immediate concern. Light-colored gastric aspirate could indicate various issues but is not as urgent as peritonitis.

5. A female client with breast cancer who completed her first chemotherapy treatment today at an outpatient center is preparing for discharge. Which behavior indicates that the client understands her care needs?

• A. Rented movies and borrowed books to use while passing time at home
• B. Made an appointment with the oncologist for follow-up treatment
• C. Expressed concern about hair loss and fatigue
• D. Asked for dietary recommendations to manage nausea

Correct answer: A

Rationale: Choice A is the correct answer. Renting movies and borrowing books to use at home indicate that the client understands the need for rest and self-care after chemotherapy. This behavior demonstrates the client's intention to engage in activities that promote relaxation and recovery. Choices B, C, and D are incorrect because making an appointment for follow-up treatment, expressing concern about side effects like hair loss and fatigue, and asking for dietary recommendations are important but do not directly reflect the client's understanding of her immediate care needs post-chemotherapy.

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