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. A client is being treated for dehydration. Which clinical finding would indicate that treatment is effective?

• A. Dry mucous membranes
• B. Increased urine output
• C. Tachycardia
• D. Hypotension

Correct answer: B

Rationale: The correct answer is B: Increased urine output. When a client is being treated for dehydration, increased urine output is a positive indication that the treatment is effective. This signifies that the body is beginning to rehydrate and eliminate excess fluid. Choices A, C, and D are incorrect because dry mucous membranes, tachycardia, and hypotension are all associated with dehydration and would not be signs of effective treatment.

3. A client is prescribed warfarin for the prevention of thromboembolism. What dietary instruction should the nurse provide?

• A. Increase intake of green leafy vegetables
• B. Maintain a consistent intake of vitamin K-rich foods
• C. Avoid all foods containing vitamin K
• D. Consume a high-protein diet

Correct answer: B

Rationale: The correct answer is B. Maintaining a consistent intake of vitamin K-rich foods is important for patients taking warfarin as it helps keep the effects of the medication stable. Choice A is incorrect because while green leafy vegetables are high in vitamin K, they should not be avoided completely but rather consumed consistently. Choice C is also incorrect as avoiding all foods containing vitamin K can lead to fluctuations in warfarin's effectiveness. Choice D is incorrect as a high-protein diet is not specifically recommended for patients taking warfarin.

4. A client with a diagnosis of tuberculosis (TB) is being discharged home. Which instruction is most important for the nurse to provide?

• A. Avoid close contact with others until treatment is complete.
• B. Take all prescribed medications as directed.
• C. Schedule a follow-up appointment with the healthcare provider.
• D. Wear a mask when in public places.

Correct answer: B

Rationale: The most important instruction for a client with tuberculosis (TB) is to take all prescribed medications as directed. This is crucial to prevent the development of drug-resistant TB. While avoiding close contact with others until treatment is complete (Choice A) is important to prevent the spread of TB, ensuring the client completes the prescribed medication regimen is the priority. Scheduling a follow-up appointment (Choice C) is important for monitoring but not as critical as medication adherence. Wearing a mask in public places (Choice D) can help reduce the spread of TB but is not as essential as taking medications as prescribed.

5. The healthcare provider plans to assess a newborn and check the infant's Moro reflex. What is the healthcare provider evaluating?

• A. Neurological integrity
• B. Renal functioning
• C. Thermoregulation
• D. Respiratory adequacy

Correct answer: A

Rationale: The Moro reflex is an instinctive response observed in newborns, indicating their neurological integrity. This reflex is evaluated by eliciting a startle response in the infant, involving the sudden extension and abduction of the limbs, followed by their retraction. This assessment helps in determining the proper functioning of the infant's nervous system and brain. Choices B, C, and D are incorrect as they do not relate to the evaluation of the Moro reflex. Renal functioning pertains to kidney function, thermoregulation refers to temperature control, and respiratory adequacy involves assessing breathing and oxygenation levels, none of which are evaluated through the Moro reflex.

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