Nursing Elites

1. A male client with a history of deep vein thrombosis (DVT) is admitted with new onset shortness of breath and a productive cough. What is the nurse's priority action?

• A. Administer prescribed anticoagulant.
• B. Notify the healthcare provider.
• C. Auscultate lung sounds.
• D. Prepare for chest physiotherapy.

Correct answer: A

Rationale: Administering an anticoagulant is the nurse's priority action in this situation. Given the client's history of DVT and the presentation of new onset shortness of breath and a productive cough, there is a concern for a pulmonary embolism, which is a life-threatening complication of DVT. Administering an anticoagulant promptly is crucial to prevent further clot formation and to manage the existing clot, reducing the risk of pulmonary embolism. While auscultating lung sounds and preparing for chest physiotherapy are important actions in respiratory assessment and management, the priority in this case is to address the potential complication of a pulmonary embolism by administering the anticoagulant. Notifying the healthcare provider can be done after initiating the immediate intervention of anticoagulant therapy.

2. A postoperative client with a history of diabetes mellitus is showing signs of hyperglycemia. What should the nurse assess first?

• A. Assess for signs of infection.
• B. Monitor the client’s fluid intake and output.
• C. Check the client’s capillary blood glucose level.
• D. Assess the client’s serum potassium level.

Correct answer: C

Rationale: The correct answer is to check the client’s capillary blood glucose level first. In a postoperative client with a history of diabetes mellitus showing signs of hyperglycemia, assessing blood glucose levels is crucial to confirm hyperglycemia and initiate appropriate interventions. While signs of infection are important to assess due to the client's postoperative status and diabetic history, checking the blood glucose level takes precedence to address the immediate concern of hyperglycemia. Monitoring fluid intake and output is essential but not the priority in this scenario. Assessing the client’s serum potassium level is important for overall assessment but not the initial step when hyperglycemia is suspected.

3. An unresponsive male victim of a diving accident is brought to the emergency department where immediate surgery is required to save his life. No family members are available. What action should the nurse take first?

• A. Ask the friend to sign an informed consent.
• B. Notify the unit manager that a court order is needed.
• C. Continue providing life support until a guardian is found.
• D. Proceed with surgery preparation without consent.

Correct answer: D

Rationale: In emergency situations where immediate surgery is required to save a patient's life and no family members are available, consent can be waived to proceed with necessary interventions. The priority in this scenario is to proceed with surgery preparation without waiting for consent, as any delay could jeopardize the patient's life. Asking the friend to sign informed consent or notifying the unit manager for a court order would cause unnecessary delays, which are not advisable in this critical situation. Continuing life support until a guardian is found is not the most appropriate action when immediate surgical intervention is necessary.

4. A client with chronic kidney disease is prescribed erythropoietin. What lab value should the nurse monitor to evaluate the effectiveness of the therapy?

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

Correct answer: B

Rationale: Erythropoietin therapy stimulates red blood cell production in clients with chronic kidney disease. Hemoglobin levels should be monitored to assess the effectiveness of the therapy and ensure the client is not developing anemia. Increased hemoglobin levels indicate successful treatment, whereas very high levels may suggest erythropoietin is overcorrecting the anemia. Monitoring the white blood cell count is not directly related to erythropoietin therapy for anemia. Serum creatinine level is used to assess kidney function rather than the effectiveness of erythropoietin therapy. Platelet count is not typically affected by erythropoietin therapy and is not a key indicator of its effectiveness.

5. A male client reports numbness and tingling in his fingers and around his mouth. What laboratory value should the nurse review?

• A. Capillary glucose.
• B. Serum calcium.
• C. Urine specific gravity.
• D. White blood cell count.

Correct answer: B

Rationale: The correct answer is B, Serum calcium. Numbness and tingling in the fingers and around the mouth are indicative of hypocalcemia, a condition characterized by low calcium levels in the blood. Reviewing the client's serum calcium levels is crucial in this situation to assess for hypocalcemia. Choice A, Capillary glucose, is incorrect because symptoms described are not typically associated with glucose abnormalities. Choice C, Urine specific gravity, and Choice D, White blood cell count, are unrelated to the symptoms presented and are not indicative of the client's condition.

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