Nursing Elites

1. A healthcare professional is caring for four clients on intravenous heparin therapy. Which lab value possibly indicates a serious side effect has occurred?

• A. Hemoglobin: 14.2 g/dL
• B. Platelet count: 82,000/µL
• C. RBC count: 4.8 x 10^6/µL
• D. WBC count: 8.7 x 10^3/µL

Correct answer: B

Rationale: A low platelet count, as seen in choice B, is concerning as it could indicate heparin-induced thrombocytopenia, a serious side effect of heparin therapy. Heparin-induced thrombocytopenia can lead to an increased risk of blood clotting, potentially causing severe complications. Monitoring platelet counts is crucial during heparin therapy to promptly identify and manage this adverse effect.

2. While assessing a client with pulmonary tuberculosis, which of the following findings should the nurse expect?

• A. Lethargy
• B. High-grade fever
• C. Weight gain
• D. Dry cough

Correct answer: A

Rationale: When assessing a client with pulmonary tuberculosis, the nurse should expect lethargy as a common finding. Tuberculosis can cause fatigue and weakness due to the body's efforts to fight the infection. High-grade fever is another common symptom of tuberculosis, not weight gain or dry cough. Weight loss is more typical in tuberculosis due to decreased appetite and systemic effects of the infection. A persistent productive cough with sputum is more characteristic of tuberculosis rather than a dry cough.

3. A client developed fat embolism syndrome (FES) following a fracture. Which of the following laboratory findings should the nurse expect?

• A. Decreased serum calcium level
• B. Decreased level of serum lipids
• C. Decreased erythrocyte sedimentation rate (ESR)
• D. Increased platelet count

Correct answer: A

Rationale: In fat embolism syndrome (FES), fat globules enter the bloodstream and can lead to various complications, including a decrease in serum calcium levels. This occurs due to the formation of fat emboli in the vessels, which can interfere with calcium metabolism. Therefore, a decreased serum calcium level is an expected laboratory finding in a client with fat embolism syndrome.

4. A nurse assesses a client who has a history of heart failure. Which question should the nurse ask to assess the extent of the client's heart failure?

• A. Do you have trouble breathing or chest pain?
• B. Are you able to walk upstairs without fatigue?
• C. Do you awake with breathlessness during the night?
• D. Do you have new-onset heaviness in your legs?

Correct answer: B

Rationale: Clients with a history of heart failure generally have negative findings, such as shortness of breath. The nurse needs to determine whether the client's activity is the same or worse, or whether the client identifies a decrease in activity level. Trouble breathing, chest pain, breathlessness at night & peripheral edema are symptoms of heart failure, but do not provide data that can determine the extent of the client's heart failure.

5. After a thoracentesis, a healthcare provider assesses a client. Which assessment finding warrants immediate action?

• A. The client rates pain as 5/10 at the site of the procedure.
• B. A small amount of drainage is noted from the site.
• C. Pulse oximetry reads 93% on 2 liters of oxygen.
• D. The trachea is deviated toward the opposite side of the neck.

Correct answer: D

Rationale: A deviated trachea indicates a tension pneumothorax, a life-threatening emergency. This condition can rapidly lead to respiratory failure and requires immediate intervention. The other assessment findings, such as pain level, mild drainage, and slightly decreased oxygen saturation, are within an expected range after a thoracentesis and do not indicate an immediate threat to the client's life.

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