Nursing Elites

1. During the initial visit, which intervention is most important for the nurse to implement?

• A. Determine how the client is cared for when the caregiver is not present.
• B. Develop a client needs assessment and review it with the caregiver.
• C. Evaluate the caregiver's ability to care for the client's needs.
• D. Review with the caregiver the interventions provided each day.

Correct answer: A

Rationale: The most important intervention for the nurse to implement during the initial visit is to determine how the client is cared for when the caregiver is not present. This is crucial for ensuring continuous and adequate care, especially for a bed-bound client with multiple sclerosis who relies heavily on the caregiver. While developing a client needs assessment (choice B) and evaluating the caregiver's ability (choice C) are important, understanding the care plan in the caregiver's absence takes precedence. Reviewing daily interventions with the caregiver (choice D) is valuable but not as critical as knowing the care plan during the caregiver's absence.

2. A client with chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation. Which intervention should the nurse implement first?

• A. Administer oxygen therapy as prescribed.
• B. Elevate the head of the bed.
• C. Obtain a sputum culture.
• D. Administer antibiotics as prescribed.

Correct answer: A

Rationale: The correct answer is to administer oxygen therapy as prescribed. In COPD exacerbation, the priority is to improve oxygenation. Administering oxygen therapy helps ensure an adequate oxygen supply to the body's tissues. Elevating the head of the bed can improve ventilation but is not the first intervention needed in this situation. Obtaining a sputum culture and administering antibiotics are important in COPD exacerbation but come after ensuring proper oxygenation.

3. A client with cirrhosis is admitted with ascites and jaundice. Which assessment finding is most concerning?

• A. Peripheral edema
• B. Confusion and altered mental status
• C. Increased abdominal girth
• D. Yellowing of the skin

Correct answer: B

Rationale: Confusion and altered mental status are concerning signs of hepatic encephalopathy in a client with cirrhosis. Hepatic encephalopathy is a serious complication of liver disease that requires immediate intervention. Peripheral edema may be present due to fluid accumulation, increased abdominal girth can indicate ascites which is common in cirrhosis, and yellowing of the skin is a typical manifestation of jaundice in liver dysfunction, all of which are important but not as immediately concerning as signs of hepatic encephalopathy.

4. A client with rheumatoid arthritis is prescribed methotrexate. Which laboratory value should the nurse monitor closely?

• A. White blood cell count of 10,000/mm³
• B. Hemoglobin of 12 g/dL
• C. Liver function tests
• D. Platelet count of 150,000/mm³

Correct answer: C

Rationale: The correct answer is C: Liver function tests. Methotrexate can cause hepatotoxicity, making it essential to closely monitor liver function tests in clients receiving this medication. Monitoring white blood cell count, hemoglobin, or platelet count is not specifically required for methotrexate therapy and would not provide relevant information regarding potential adverse effects of the medication.

5. A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation. Which laboratory value should be monitored closely?

• A. Arterial blood gas (ABG) values
• B. Serum potassium level
• C. Serum sodium level
• D. Serum magnesium level

Correct answer: B

Rationale: The correct answer is B: Serum potassium level. In COPD, especially when the client is receiving diuretics or corticosteroids, monitoring serum potassium levels is crucial. These medications can lead to potassium loss, potentially causing hypokalemia. Arterial blood gas (choice A) values are important in assessing respiratory status but are not the primary concern related to medication side effects. Serum sodium (choice C) and magnesium (choice D) levels are also important, but in the context of COPD exacerbation and medication effects, potassium monitoring takes precedence.

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