Nursing Elites

1. A client with liver cirrhosis and severe ascites has a serum sodium level of 115 mEq/L and is receiving 3% saline IV. Which assessment finding indicates that the nurse should notify the healthcare provider?

• A. The client's serum sodium level is now 130 mEq/L
• B. The client reports a headache and has a BP of 140/90
• C. The client reports shortness of breath and has an O2 saturation of 92%
• D. The client has crackles in both lung bases and an increased respiratory rate.

Correct answer: D

Rationale: The presence of crackles in both lung bases and an increased respiratory rate indicates fluid overload, which can be exacerbated by hypertonic saline. This condition can worsen the client's respiratory status and lead to further complications. The other options do not directly relate to the fluid overload caused by the hypertonic saline. A serum sodium level of 130 mEq/L is within a normal range for treatment. A headache and a blood pressure of 140/90 are not specific indicators of worsening condition related to hypertonic saline. Shortness of breath and an O2 saturation of 92% could be related to other factors in a client with liver cirrhosis and ascites.

2. The nurse is caring for a client with a chest tube following a pneumothorax. Which assessment finding requires immediate intervention?

• A. Oxygen saturation of 94%
• B. Subcutaneous emphysema
• C. Crepitus around the insertion site
• D. Drainage of 50 ml per hour

Correct answer: B

Rationale: Subcutaneous emphysema is the correct answer as it is most concerning in a client with a chest tube following a pneumothorax. It may indicate a pneumothorax recurrence or air leak, requiring immediate intervention to prevent complications. Oxygen saturation of 94% is acceptable and does not require immediate intervention. Crepitus around the insertion site may be a normal finding after chest tube placement and does not necessarily indicate a complication. Drainage of 50 ml per hour is within the expected range for a chest tube and does not require immediate intervention.

3. A client who developed syndrome of inappropriate antidiuretic hormone (SIADH) associated with small carcinoma of the lung is preparing for discharge. When teaching the client about self-management with demeclocycline (Declomycin), the nurse should instruct the client to report which condition to the healthcare provider?

• A. Insomnia
• B. Muscle cramping
• C. Increased appetite
• D. Anxiety

Correct answer: B

Rationale: The correct answer is B: Muscle cramping. SIADH causes dilutional hyponatremia due to increased ADH release. Demeclocycline is used to block the action of ADH. Muscle cramping can indicate electrolyte imbalances related to hyponatremia, which should be reported to the healthcare provider. Insomnia, increased appetite, and anxiety are not typically associated with the side effects or complications of demeclocycline or SIADH.

4. What is the first action the nurse should implement for a client admitted with acute pancreatitis?

• A. Administer intravenous fluids as prescribed
• B. Administer pain medication as prescribed
• C. Place the client on NPO status
• D. Assess the client's abdomen for distention

Correct answer: C

Rationale: Placing the client on NPO status is the priority action for a client with acute pancreatitis. This step is crucial to rest the pancreas, prevent pancreatic stimulation, and decrease enzyme production. By withholding oral intake, the digestive system is given a chance to rest and recover. Administering intravenous fluids may be necessary but should come after placing the client on NPO status. Pain medication can be administered once the client is stabilized. Assessing the client's abdomen for distention is important but is not the initial priority in managing acute pancreatitis.

5. A male client with impaired renal function who takes ibuprofen daily for chronic arthritis is showing signs of gastrointestinal (GI) bleeding. After administering IV fluids and a blood transfusion, his blood pressure is 100/70 mm Hg, and his renal output is 20 ml/hour. Which intervention should the nurse include in his care plan?

• A. Maintain the client NPO during the diuresis phase.
• B. Evaluate daily serial renal laboratory studies for progressive elevations.
• C. Observe the urine character for sedimentation and cloudy appearance.
• D. Monitor for the onset of polyuria greater than 150 ml/hour.

Correct answer: B

Rationale: In this scenario, the correct intervention for the nurse to include in the care plan is to evaluate daily serial renal laboratory studies for progressive elevations. This is crucial in monitoring renal function and detecting any worsening renal impairment. Option A is not directly related to managing renal function in this case. Option C focuses more on urinary characteristics rather than renal function monitoring. Option D addresses polyuria, which is an excessive urine output, but it does not specifically address the need for evaluating renal laboratory studies for progressive elevations.

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