Nursing Elites

1. The nurse administers 2 units of salt-poor albumin to a client with portal hypertension and ascites. The nurse explains to the client that this is administered to:

• A. Provide nutrients
• B. Increase protein stores
• C. Elevate the circulating blood volume
• D. Divert blood flow away from the liver temporarily

Correct answer: C

Rationale: The correct answer is C: Elevate the circulating blood volume. Salt-poor albumin is given to increase the circulating blood volume, which helps reduce ascites by improving fluid distribution within the body. Choices A, B, and D are incorrect because salt-poor albumin is not administered to provide nutrients, increase protein stores, or divert blood flow away from the liver.

2. When a patient is prescribed an oral anticoagulant, what should the nurse monitor for?

• A. Elevated blood glucose
• B. Decreased blood pressure
• C. Signs of bleeding
• D. Increased appetite

Correct answer: C

Rationale: When a patient is prescribed an oral anticoagulant, the nurse should monitor for signs of bleeding. Oral anticoagulants work by inhibiting the blood's ability to clot, which increases the risk of bleeding. Monitoring for signs of bleeding such as easy bruising, petechiae, hematuria, or bleeding gums is crucial to prevent complications. Elevated blood glucose (Choice A) is not directly related to oral anticoagulant use. Decreased blood pressure (Choice B) is not a common effect of oral anticoagulants. Increased appetite (Choice D) is not a typical side effect of oral anticoagulants and is not a primary concern when monitoring a patient on this medication.

3. In patients receiving chemotherapy, which nutrient is often supplemented to manage mucositis?

• A. Vitamin E
• B. Vitamin B12
• C. Zinc
• D. Calcium

Correct answer: C

Rationale: Zinc supplementation is often used to manage mucositis in patients receiving chemotherapy. Zinc has been shown to aid in the healing process of mucositis. Vitamin E (Choice A) is not typically used to manage mucositis associated with chemotherapy. Vitamin B12 (Choice B) is essential for nerve function and the formation of red blood cells, but it is not primarily used to manage mucositis. Calcium (Choice D) is important for bone health and nerve function but is not specifically used to manage mucositis.

4. The nurse is caring for a client diagnosed with rule-out nephritic syndrome. Which intervention should be included in the plan of care?

• A. Monitor the urine for bright-red bleeding
• B. Evaluate the calorie count of the 500-mg protein diet
• C. Assess the client’s sacrum for dependent edema
• D. Monitor for a high serum albumin level

Correct answer: C

Rationale: Assessing the client’s sacrum for dependent edema is crucial in the care plan for nephritic syndrome as it is common due to protein loss. Dependent edema occurs as a result of decreased oncotic pressure from protein loss in the urine. Monitoring urine for bright-red bleeding (choice A) is more relevant to conditions like glomerulonephritis. Evaluating calorie count or protein intake (choice B) is important for other conditions but not specifically for nephritic syndrome. Monitoring for a high serum albumin level (choice D) is not typically part of the immediate care plan for nephritic syndrome.

5. The nurse is caring for a client in a sickle cell crisis. Which is the pain regimen of choice to relieve the pain?

• A. Frequent aspirin (acetylsalicylic acid) and a non-narcotic analgesic
• B. Motrin (ibuprofen), an NSAID, PRN
• C. Demerol (meperidine), a narcotic analgesic, every four (4) hours
• D. Morphine, a narcotic analgesic, every two (2) to three (3) hours PRN

Correct answer: D

Rationale: In a sickle cell crisis, morphine is the preferred analgesic due to its potency and effectiveness in managing severe pain. Choice A is incorrect because aspirin is contraindicated in sickle cell disease due to its potential to cause a further decrease in blood flow. Choice B, Motrin (ibuprofen), is also not the ideal choice as NSAIDs can exacerbate renal complications in sickle cell patients. Choice C, Demerol (meperidine), is not recommended for sickle cell pain management due to its toxic metabolite accumulation which can cause seizures and other complications.

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