Nursing Elites

1. A nurse is caring for a client who is receiving chemotherapy. Which of the following laboratory values should the nurse report to the provider?

• A. WBC 4,500/mm3
• B. Hemoglobin 12 g/dL
• C. Platelet count 250,000/mm3
• D. Platelet count 100,000/mm3

Correct answer: D

Rationale: The correct answer is D. A platelet count of 100,000/mm3 is lower than the normal range, indicating thrombocytopenia, which is concerning in clients receiving chemotherapy. Thrombocytopenia can lead to an increased risk of bleeding and bruising. Choices A, B, and C fall within the normal range and would not be a cause for concern in a client receiving chemotherapy.

2. What is the most important nursing action when a patient has a central line?

• A. Monitor for infection
• B. Monitor the central line dressing
• C. Monitor for redness
• D. Monitor for swelling

Correct answer: A

Rationale: The most important nursing action when a patient has a central line is to monitor for infection. Central line-associated bloodstream infections are a serious complication that can lead to severe outcomes. Monitoring for infection involves assessing the patient for signs and symptoms such as fever, chills, and hypotension. While monitoring the central line dressing, redness, and swelling are also important aspects of care, they are secondary to monitoring for infection as the primary focus should be on preventing serious complications.

3. A nurse is assessing a client who has chronic obstructive pulmonary disease (COPD). Which of the following findings should the nurse report to the provider?

• A. Oxygen saturation of 91%
• B. Use of pursed-lip breathing
• C. Productive cough with green sputum
• D. Decreased breath sounds in the right lower lobe

Correct answer: D

Rationale: The correct finding the nurse should report to the provider is decreased breath sounds in the right lower lobe. This can indicate a respiratory infection or atelectasis in clients with COPD, requiring further evaluation and intervention. Choice A, an oxygen saturation of 91%, although slightly lower than normal, does not necessarily require immediate reporting unless the client's baseline is significantly higher. Choice B, the use of pursed-lip breathing, is actually a beneficial technique for clients with COPD to improve oxygenation and reduce shortness of breath, so it does not need reporting. Choice C, a productive cough with green sputum, can be common in clients with COPD and may indicate an infection, but it is not as concerning as decreased breath sounds in a specific lung lobe which may signify a more acute issue.

4. What is the priority nursing intervention for a patient with hyperkalemia?

• A. Administer calcium gluconate
• B. Administer insulin
• C. Administer sodium bicarbonate
• D. Administer a diuretic

Correct answer: A

Rationale: The correct answer is to administer calcium gluconate. In hyperkalemia, the priority is to protect the heart from potential complications like arrhythmias. Calcium gluconate is the first-line treatment as it stabilizes the cardiac cell membrane. Insulin (Choice B) and sodium bicarbonate (Choice C) can be used in conjunction with other treatments to shift potassium into cells, but calcium gluconate is the priority. Administering a diuretic (Choice D) is not the primary intervention for hyperkalemia and can even worsen the condition by reducing potassium excretion.

5. A nurse is assessing a client who has cirrhosis. Which of the following findings should the nurse expect?

• A. Clay-colored stools.
• B. Hypertension.
• C. Stridor.
• D. Elevated temperature.

Correct answer: A

Rationale: Clay-colored stools are a classic finding in a client with cirrhosis. Cirrhosis can lead to impaired bile flow, resulting in pale or clay-colored stools due to a lack of bilirubin in the stool. Hypertension, stridor, and elevated temperature are not typically associated with cirrhosis. Hypertension may occur in cirrhosis but is not a consistent finding, stridor is more commonly associated with upper airway obstruction, and elevated temperature may indicate an infection rather than a direct result of cirrhosis.

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