Nursing Elites

1. Why is a low-protein diet recommended for a client with hepatic encephalopathy?

• A. Hyperglycemia
• B. Hypoglycemia
• C. Increased ammonia levels
• D. Electrolyte imbalance

Correct answer: C

Rationale: A low-protein diet is recommended for clients with hepatic encephalopathy to reduce ammonia levels. Ammonia, a byproduct of protein metabolism, can accumulate in the blood due to impaired liver function. Elevated ammonia levels can lead to worsening hepatic encephalopathy, a condition characterized by cognitive and neurological disturbances. Therefore, by limiting protein intake, the production of ammonia is reduced, thereby helping to manage hepatic encephalopathy. Choices A, B, and D are incorrect because hepatic encephalopathy is not primarily related to hyperglycemia, hypoglycemia, or electrolyte imbalance. The focus is on reducing ammonia levels to improve the condition.

2. What should be monitored to evaluate the effectiveness of enoxaparin in a patient with deep vein thrombosis (DVT)?

• A. Prothrombin time (PT)
• B. Partial thromboplastin time (PTT)
• C. International normalized ratio (INR)
• D. Platelet count

Correct answer: C

Rationale: The international normalized ratio (INR) is the appropriate parameter to monitor the effectiveness of enoxaparin in preventing clot formation in patients with deep vein thrombosis (DVT). INR reflects the clotting ability of the blood and is commonly used to assess the therapeutic range of anticoagulant medications, such as enoxaparin, which is crucial in managing and preventing thrombotic events like DVT.

3. A male client is admitted to the neurological unit. He has just sustained a C-5 spinal cord injury. Which assessment finding of this client warrants immediate intervention by the nurse?

• A. Is unable to feel sensation in the arms and hands.
• B. Has flaccid upper and lower extremities.
• C. Blood pressure is 110/70 and the apical pulse is 68.
• D. Respirations are shallow, labored, and 14 breaths/minute.

Correct answer: D

Rationale: Respirations that are shallow, labored, and at 14 breaths/minute indicate potential respiratory compromise, which is a critical situation requiring immediate intervention to maintain adequate oxygenation and prevent respiratory failure.

4. A healthcare professional is assessing a client with severe dehydration. Which finding indicates a need for immediate intervention?

• A. Heart rate of 110 beats per minute.
• B. Blood pressure of 90/60 mm Hg.
• C. Urine output of 20 ml/hour.
• D. Dry mucous membranes.

Correct answer: C

Rationale: A urine output of 20 ml/hour indicates severe dehydration and impaired renal function. This finding suggests a critical state where the kidneys are conserving water, leading to reduced urine output. Immediate intervention is required to restore fluid balance and prevent further complications associated with severe dehydration. Choice A, a heart rate of 110 beats per minute, may indicate dehydration but is not as severe as the critically low urine output. Choice B, a blood pressure of 90/60 mm Hg, can be seen in dehydration but is not as concerning as the extremely low urine output. Choice D, dry mucous membranes, is a common sign of dehydration but does not require immediate intervention compared to the severely reduced urine output.

5. A male infant born at 30-weeks gestation at an outlying hospital is being prepared for transport to a Level IV neonatal facility. His respirations are 90/min, and his heart rate is 150 beats per minute. Which drug is the transport team most likely to administer to this infant?

• A. Ampicillin (Omnipen) 25 mg/kg slow IV push.
• B. Gentamicin sulfate (Garamycin) 2.5 mg/kg IV.
• C. Digoxin (Lanoxin) 20 micrograms/kg IV.
• D. Beractant (Survanta) 100 mg/kg per endotracheal tube.

Correct answer: D

Rationale: In this scenario, the infant is a preterm neonate with respiratory distress and is being transported to a Level IV neonatal facility. The drug most likely to be administered by the transport team is Beractant (Survanta) via endotracheal tube. Beractant is a surfactant used to treat respiratory distress syndrome in preterm infants by improving lung compliance and reducing the need for mechanical ventilation.

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