Nursing Elites

1. A healthcare professional is reviewing the laboratory values of a client who has cirrhosis. Which of the following findings should the healthcare professional report to the provider?

• A. Ammonia 75 mcg/dL
• B. Sodium 142 mEq/L
• C. Calcium 9.5 mg/dL
• D. Bilirubin 2.5 mg/dL

Correct answer: D

Rationale: An elevated bilirubin level in clients with cirrhosis indicates worsening liver function and potential complications. It is crucial to report this finding promptly as it may require immediate medical intervention. Elevated ammonia levels (choice A) are also concerning in cirrhosis, indicating hepatic encephalopathy, but bilirubin levels are more specific to liver function in this context. Choices B and C are within normal ranges and are not typically of immediate concern in cirrhosis.

2. A nurse is admitting a client who is in labor and at 38 wks of gestation to the maternal newborn unit. The client has a history of herpes simplex virus 2. Which of the following questions is most appropriate for the nurse to ask the client?

• A. Have your membranes ruptured?
• B. How far apart are your contractions?
• C. Do you have any active lesions?
• D. Are you positive for beta strep?

Correct answer: C

Rationale: The most appropriate question for the nurse to ask the client in this situation is whether they have any active lesions due to the history of herpes simplex virus. This is crucial to assess the risk of transmission to the newborn during labor. Option A is not the priority in this case as the focus is on the client's history of herpes simplex virus. Option B is important but does not directly relate to the risk of herpes simplex virus transmission. Option D is unrelated to the client's condition and the current situation.

3. What is the appropriate diet for a patient with chronic kidney disease?

• A. Low protein diet
• B. High protein diet
• C. Low sodium diet
• D. Low potassium diet

Correct answer: A

Rationale: A low protein diet is the appropriate choice for a patient with chronic kidney disease because it helps to reduce the buildup of waste products in the body, which the kidneys may struggle to filter out. High protein diets can put extra strain on the kidneys by increasing the workload to eliminate the byproducts of protein metabolism. While low sodium and low potassium diets can also be important for managing certain aspects of kidney disease, the primary focus should be on controlling protein intake to lessen the burden on the kidneys.

4. A nurse is caring for a client who is postoperative following an abdominal surgery. Which of the following assessments should the nurse prioritize?

• A. Assess the client's pain level.
• B. Monitor the client's respiratory rate.
• C. Measure the client's blood pressure.
• D. Check the client's bowel sounds.

Correct answer: B

Rationale: The correct answer is to monitor the client's respiratory rate. This assessment is crucial in the postoperative period to detect any respiratory complications such as hypoxia or respiratory distress. Assessing pain level (Choice A) is important but may not be the top priority as respiratory status takes precedence. Measuring blood pressure (Choice C) is also important but not as critical immediately postoperatively as monitoring respiratory function. Checking bowel sounds (Choice D) is relevant for assessing gastrointestinal function but is typically not the top priority in the immediate postoperative phase.

5. A client has deep vein thrombosis (DVT). Which of the following actions should the nurse take?

• A. Administer thrombolytics as prescribed.
• B. Massage the affected extremity every 2 hours.
• C. Apply warm compresses to the affected extremity.
• D. Place the client in a supine position with the legs elevated.

Correct answer: C

Rationale: The correct action for a nurse caring for a client with deep vein thrombosis (DVT) is to apply warm compresses to the affected extremity. Warm compresses help reduce swelling and pain in clients with DVT. Administering thrombolytics (Choice A) is not typically done without specific orders due to the risk of bleeding. Massaging the affected extremity (Choice B) can dislodge blood clots and lead to complications. Placing the client in a supine position with the legs elevated (Choice D) may increase the risk of clot dislodgment.

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