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 client is 2 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?

• A. Position the client supine with a pillow between the legs.
• B. Place an abduction pillow between the client's legs.
• C. Place a pillow under the client's knees.
• D. Position the client's legs in adduction.

Correct answer: B

Rationale: After a total hip arthroplasty, it is crucial to prevent hip dislocation. Placing an abduction pillow between the client's legs helps maintain proper alignment of the hip joint and prevents adduction, which could lead to dislocation. Therefore, choice B is the correct action. Choice A is incorrect because positioning the client supine with a pillow between the legs does not provide the necessary abduction to prevent dislocation. Choice C, placing a pillow under the client's knees, does not address the need for abduction. Choice D, positioning the client's legs in adduction, is incorrect as adduction increases the risk of hip dislocation following hip arthroplasty.

3. A nurse is caring for a client who is postpartum and reports perineal pain. Which intervention should the nurse implement?

• A. Administer analgesics as prescribed.
• B. Apply a warm compress to the perineum.
• C. Encourage the client to ambulate frequently.
• D. Position the client with the head elevated.

Correct answer: A

Rationale: Administering analgesics as prescribed is the appropriate intervention for managing perineal pain in a postpartum client. Analgesics help to alleviate discomfort and promote the client's recovery. Applying a warm compress (choice B) may provide some relief, but it does not address the pain as effectively as analgesics. Encouraging ambulation (choice C) and positioning the client with the head elevated (choice D) are not directly related to addressing perineal pain.

4. A client with a nasogastric tube receiving continuous enteral feedings is at risk for aspiration. Which of the following actions should the nurse take to prevent aspiration?

• A. Elevate the head of the bed to 15 degrees
• B. Check gastric residual volumes every 6 hours
• C. Monitor the pH of gastric aspirate
• D. Instill 10 mL of air into the tube before feeding

Correct answer: B

Rationale: Checking gastric residual volumes every 6 hours is essential in preventing aspiration in clients receiving continuous enteral feedings. This practice helps determine if the stomach is adequately emptying, reducing the risk of regurgitation and aspiration. Elevating the head of the bed to 30 degrees, not 15 degrees, is recommended to further prevent aspiration by reducing the risk of reflux. Monitoring the pH of gastric aspirate is important to assess tube placement but does not directly prevent aspiration. Instilling air into the tube before feeding is not a recommended practice and does not prevent aspiration.

5. A client with iron deficiency anemia has a new prescription for ferrous sulfate. Which of the following instructions should the nurse include?

• A. Take with a glass of milk to prevent stomach upset.
• B. Take with orange juice to enhance absorption.
• C. Take on an empty stomach to increase absorption.
• D. Take with food to reduce gastrointestinal upset.

Correct answer: C

Rationale: The correct instruction is to take ferrous sulfate on an empty stomach to increase absorption. This is because taking it with food or dairy products like milk can reduce its absorption. Orange juice is not recommended as it may interfere with the absorption of iron. Taking ferrous sulfate on an empty stomach may cause gastrointestinal upset, but this can be minimized by gradually increasing the dose.

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