Nursing Elites

1. When caring for a client with Cushing syndrome, which serum laboratory value is most important for the nurse to monitor?

• A. Lactate
• B. Glucose
• C. Hemoglobin
• D. Creatinine

Correct answer: B

Rationale: When caring for a client with Cushing syndrome, monitoring glucose levels is crucial as Cushing syndrome often leads to hyperglycemia. Elevated glucose levels are a common manifestation of Cushing syndrome due to increased cortisol levels. Monitoring glucose helps in assessing and managing the client's condition effectively. Lactate levels are not typically affected by Cushing syndrome. Hemoglobin and creatinine levels are important for other conditions like anemia and kidney function, but they are not the priority in Cushing syndrome.

2. A client taking clopidogrel reports the onset of diarrhea. Which nursing action should the nurse implement first?

• A. Observe the appearance of the stool
• B. Assess the client’s skin turgor
• C. Review the client’s laboratory values
• D. Auscultate the client’s bowel sounds

Correct answer: A

Rationale: Observing the stool’s appearance should be implemented first as it helps determine the nature and possible severity of the diarrhea, which is essential in managing the side effect. Assessing skin turgor (Choice B) is not the priority in this situation. Reviewing laboratory values (Choice C) can provide additional information but is not the initial step. Auscultating bowel sounds (Choice D) is not the priority when the client is experiencing diarrhea.

3. A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which assessment finding warrants immediate intervention by the nurse?

• A. The client has asymmetrical chest wall expansion
• B. The client complains of pain at the insertion site
• C. The client's chest x-ray indicates decreased pleural effusion
• D. The client's arterial blood gases show pH 7.35, PaO2 85, PaCO2 35, HCO3 26

Correct answer: A

Rationale: Asymmetrical chest wall expansion is a critical finding post-thoracentesis as it may suggest a pneumothorax, requiring immediate intervention to prevent further complications. The other options, such as pain at the insertion site (Choice B), decreased pleural effusion on chest x-ray (Choice C), and normal arterial blood gases within acceptable ranges (Choice D) do not indicate an immediate need for intervention like asymmetrical chest wall expansion does.

4. A mother brings her child, who has a history of asthma, to the emergency room. The child is wheezing and speaking one word between each breath. The child is anxious, tachycardic, and has labored respirations. Which assessment is most important for the nurse to obtain?

• A. Type of inhaler the child typically uses on a regular basis
• B. Frequency of rescue inhaler use during the week
• C. Last dose and type of rescue inhaler used by the child
• D. Type of allergen exposure or trigger for the current episode

Correct answer: C

Rationale: The correct answer is C because knowing the last dose and type of rescue inhaler used helps assess if the child has received adequate treatment and if further intervention is needed. This information is crucial in managing an acute asthma exacerbation. Choice A, the type of inhaler the child typically uses, is less critical during an emergency. Choice B, the frequency of rescue inhaler use during the week, is important for general asthma management but does not provide immediate guidance in the acute situation. Choice D, the type of allergen exposure or trigger, is more relevant for preventive strategies and does not directly impact the immediate treatment of the child's acute asthma attack.

5. A male client approaches the nurse with an angry expression on his face and raises his voice, saying, “My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch him out.” The nurse recognizes that the client is using which defense mechanism?

• A. Denial
• B. Splitting
• C. Projection
• D. Rationalization

Correct answer: C

Rationale: The client is projecting his feelings of anger and frustration onto his roommate, attributing his own feelings to the other person. Projection is a defense mechanism where individuals attribute their thoughts, feelings, or motives onto another person. In this scenario, the client is displacing his anger onto his roommate, thereby using projection as a defense mechanism. Denial (choice A) is refusing to acknowledge an aspect of reality. Splitting (choice B) involves viewing people as all good or all bad. Rationalization (choice D) is creating logical explanations to justify unacceptable behavior.

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