Nursing Elites

1. After receiving a report, the nurse receives the laboratory values for four clients. Which client requires the nurse’s immediate intervention? The client who is...

• A. Short of breath after a shower and has a hemoglobin of 8 grams
• B. Bleeding from a finger stick and has a prothrombin time of 30 seconds
• C. Febrile and has a WBC count of 14,000/mm3
• D. Trembling and has a glucose level of 50 mg/dL

Correct answer: D

Rationale: A glucose level of 50 mg/dL is indicative of hypoglycemia, which requires immediate intervention to prevent further complications. Hypoglycemia can lead to serious consequences such as altered mental status, seizures, and even coma if not promptly addressed. The other options do not present immediate life-threatening conditions that require urgent intervention. Shortness of breath with a hemoglobin of 8 grams may indicate anemia but does not require immediate intervention. Bleeding from a finger stick with a prothrombin time of 30 seconds may suggest clotting issues, which are important but not as immediately critical as hypoglycemia. Being febrile with an elevated WBC count could indicate infection, which is concerning but not as urgently critical as hypoglycemia.

2. The nurse plans to administer the rubella vaccine to a postpartum client whose titer is < 1:8 and who is breastfeeding. What information should the nurse provide this client?

• A. The client should bottle feed and pump her breast for 3 days following immunization
• B. The vaccine is given to produce maternal antibodies before lactation occurs
• C. The infant will receive immunization through the mother's breast milk
• D. The client should not get pregnant for 3 months after immunization

Correct answer: D

Rationale: Educating about the waiting period helps prevent possible rubella infection in a subsequent early pregnancy.

3. A client with chronic kidney disease (CKD) is receiving erythropoietin therapy. What is the primary purpose of this medication?

• A. To lower blood pressure
• B. To improve appetite
• C. To increase red blood cell production
• D. To reduce fluid retention

Correct answer: C

Rationale: The correct answer is C: 'To increase red blood cell production.' Erythropoietin stimulates the production of red blood cells to treat anemia associated with CKD. Choices A, B, and D are incorrect because erythropoietin therapy is primarily used to address anemia by increasing the production of red blood cells rather than lowering blood pressure, improving appetite, or reducing fluid retention.

4. The nurse is assessing a client with left-sided heart failure. Which symptom should the nurse expect to find?

• A. Peripheral edema
• B. Jugular vein distention
• C. Shortness of breath
• D. Weight gain

Correct answer: C

Rationale: Shortness of breath is a characteristic symptom of left-sided heart failure. In this condition, the heart's inability to effectively pump blood forward causes blood to back up into the lungs, leading to fluid accumulation. This fluid accumulation results in pulmonary congestion, manifesting as shortness of breath or difficulty breathing. Peripheral edema (choice A) is more commonly associated with right-sided heart failure, where fluid accumulates in the extremities. Jugular vein distention (choice B) is a sign of increased central venous pressure and is more indicative of right-sided heart failure. Weight gain (choice D) can be a general symptom of heart failure due to fluid retention, but shortness of breath is specifically related to left-sided heart failure.

5. A client is admitted with Atrial Fibrillation and is administered amiodarone (Cordarone). What therapeutic response should the nurse anticipate?

• A. Conversion of irregular heart rate to regular heart rhythm
• B. Pulse oximetry readings within normal range during activity
• C. Peripheral pulse points with adequate capillary refill
• D. Increase in exercise tolerance without shortness of breath

Correct answer: A

Rationale: The correct answer is A: Conversion of irregular heart rate to regular heart rhythm. Amiodarone is a medication commonly used to restore and maintain normal heart rhythm in clients with atrial fibrillation. It works by slowing down the electrical signals in the heart, helping to regulate the heartbeat. Choices B, C, and D are incorrect because they do not directly relate to the therapeutic response expected from administering amiodarone in a client with atrial fibrillation. Pulse oximetry readings, peripheral pulses, capillary refill, and exercise tolerance are important assessments but are not the primary therapeutic goal of using amiodarone in this situation.

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