Nursing Elites

1. When preparing a client for transfer to the ICU for placement of a pulmonary artery catheter, the nurse should explain that this catheter is used to monitor which of the following conditions?

• A. Intracranial pressure
• B. Spinal cord perfusion
• C. Renal function
• D. Hemodynamic status

Correct answer: D

Rationale: A pulmonary artery catheter is primarily used to monitor hemodynamic status. It provides essential information on cardiac output, preload, afterload, and overall cardiovascular function. This data helps healthcare providers manage the client's fluid status, cardiac function, and guide treatment interventions in critically ill patients. Monitoring intracranial pressure, spinal cord perfusion, or renal function would require different monitoring devices and techniques, not a pulmonary artery catheter.

2. A nurse is caring for a client post-myocardial infarction (MI). What is the priority assessment for this client?

• A. Monitoring urine output
• B. Checking blood glucose levels
• C. Assessing for chest pain
• D. Monitoring electrolyte levels

Correct answer: C

Rationale: Assessing for chest pain is crucial in post-MI clients as it can indicate complications such as reinfarction or ischemia.

3. 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.

4. A client has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor?

• A. Confusion
• B. Weakness
• C. Increased intracranial pressure
• D. Increased urinary output

Correct answer: B

Rationale: In myasthenia gravis, a neuromuscular disorder characterized by muscle weakness and fatigue, weakness is a common manifestation due to the immune system attacking the communication between nerves and muscles. Monitoring for weakness is crucial to assess the disease progression and determine the effectiveness of treatment. Confusion is not a typical manifestation of myasthenia gravis. Increased intracranial pressure and increased urinary output are not directly associated with this condition.

5. A client with acute respiratory failure (ARF) is being cared for by a nurse. The nurse should monitor the client for which of the following manifestations of this condition?

• A. Severe dyspnea
• B. Nausea
• C. Decreased level of consciousness
• D. Headache

Correct answer: B

Rationale: In acute respiratory failure, the body is not getting enough oxygen, leading to hypoxia. Symptoms of hypoxia include severe dyspnea (A), decreased level of consciousness (C), and headache (D) due to inadequate oxygen supply to the brain. Nausea (B) is not a typical manifestation of acute respiratory failure and is not directly related to the lack of oxygen in the body. Therefore, the nurse should not monitor the client for nausea as a direct consequence of ARF.

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