Nursing Elites

1. A nurse is reviewing the laboratory results for a client who has end-stage liver disease. Which of the following findings should the nurse expect?

• A. Elevated albumin
• B. Elevated ammonia
• C. Decreased total bilirubin
• D. Decreased prothrombin time

Correct answer: B

Rationale: In end-stage liver disease, the liver's inability to convert ammonia into urea leads to elevated ammonia levels. Elevated ammonia levels can result in hepatic encephalopathy, a serious complication. Therefore, the correct answer is B. Elevated albumin (Choice A) is not typically seen in end-stage liver disease as liver dysfunction often leads to decreased albumin levels. Decreased total bilirubin (Choice C) is unlikely in end-stage liver disease, as bilirubin levels tend to be elevated due to impaired liver function. Decreased prothrombin time (Choice D) is also not expected in end-stage liver disease, as impaired liver function results in prolonged prothrombin time.

2. A healthcare professional is preparing to transfer a client from a chair to a bed. The client can bear partial weight and has upper body strength. Which device should the healthcare professional use?

• A. Hydraulic lift
• B. Stand-assist lift
• C. Wheelchair
• D. Mechanical lift

Correct answer: B

Rationale: A stand-assist lift is the appropriate device for transferring a client who can bear partial weight and has upper body strength. This device provides support for the client to stand up and be transferred safely. A hydraulic lift is more suitable for transferring clients who cannot bear weight. A wheelchair is used for mobility but not for transferring between a chair and a bed. A mechanical lift is typically used for transferring clients who are unable to bear weight or have limited mobility.

3. A nurse is preparing to perform a sterile dressing change for a client who has a surgical wound. Which of the following actions should the nurse take to prevent contamination during the dressing change?

• A. Use sterile gloves only as necessary
• B. Restart the procedure if the sterile solution splashes onto the sterile field while pouring the solution into the dressing tray
• C. Keep the dressing tray on a nearby surface
• D. Avoid speaking during the procedure

Correct answer: B

Rationale: The correct action to prevent contamination during a sterile dressing change is to restart the procedure if the sterile solution splashes onto the sterile field while pouring the solution into the dressing tray. Any contact with the sterile field by non-sterile items makes the field contaminated and requires restarting the procedure to maintain sterility. Choice A is incorrect because sterile gloves should always be used during a sterile procedure to prevent contamination. Choice C is incorrect as the dressing tray should be placed on a sterile surface, not on the client's bed, to maintain sterility. Choice D is also incorrect as talking during the procedure does not necessarily lead to contamination if proper aseptic technique is maintained.

4. A healthcare professional is assessing a client with deep vein thrombosis (DVT). Which of the following interventions should the healthcare professional include in the plan of care?

• A. Apply ice packs to the affected extremity.
• B. Encourage ambulation every hour.
• C. Elevate the affected leg when in bed.
• D. Massage the affected area to improve circulation.

Correct answer: C

Rationale: Elevating the affected leg is a crucial intervention in the care of a client with deep vein thrombosis (DVT). This position helps reduce swelling and promotes venous return, which can alleviate symptoms associated with DVT. Applying ice packs (Choice A) may worsen the condition by causing vasoconstriction. Encouraging ambulation (Choice B) can dislodge the clot and lead to fatal complications. Massaging the affected area (Choice D) can also dislodge the clot and is contraindicated in DVT.

5. A nurse is teaching about measures to promote sleep for a client with insomnia. What statement indicates understanding?

• A. I should reduce my fluid intake to 2 hours before bedtime
• B. I will watch TV in bed before sleeping
• C. I can take long naps during the day
• D. I should exercise right before going to bed

Correct answer: A

Rationale: The correct answer is A. Reducing fluid intake to 2-4 hours before sleeping helps prevent interruptions during the night, promoting better sleep. Watching TV in bed before sleeping (choice B) can actually hinder sleep due to the stimulation from screens. Taking long naps during the day (choice C) can disrupt the natural sleep-wake cycle. Exercising right before going to bed (choice D) can increase alertness and make it harder to fall asleep.

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