Nursing Elites

1. The nurse is assessing a client with chronic liver disease. Which lab value is most concerning?

• A. Elevated AST and ALT levels
• B. Decreased albumin level
• C. Elevated bilirubin level
• D. Prolonged PT/INR

Correct answer: D

Rationale: In a client with chronic liver disease, a prolonged PT/INR is the most concerning lab value. This finding indicates impaired liver function affecting the synthesis of clotting factors, leading to an increased risk of bleeding. Elevated AST and ALT levels (Choice A) indicate liver cell damage but do not directly correlate with the risk of bleeding. A decreased albumin level (Choice B) is common in liver disease but is not the most concerning in terms of bleeding risk. Elevated bilirubin levels (Choice C) are seen in liver disease but do not directly reflect the risk of bleeding as PT/INR values do.

2. While caring for a client who is being mechanically ventilated, the nurse responds to a high-pressure alarm on the ventilator. Which assessment finding warrants immediate intervention by the nurse?

• A. Endotracheal cuff pressure greater than 25 cm H2O.
• B. Decreased lung compliance during ventilation.
• C. Bilateral crackles with increased secretions.
• D. Restless client who is biting the endotracheal tube.

Correct answer: D

Rationale: A restless client biting the endotracheal tube can increase airway resistance, triggering the high-pressure alarm and indicating a need for immediate intervention. This behavior can lead to complications such as dislodgement of the tube or airway obstruction. Endotracheal cuff pressure greater than 25 cm H2O, decreased lung compliance, and bilateral crackles with increased secretions are important assessments but do not directly address the urgent need to intervene when a high-pressure alarm is triggered.

3. A client with a diagnosis of anemia is being discharged with a prescription for ferrous sulfate. What should the nurse include in the teaching plan?

• A. Take the medication with milk to enhance absorption
• B. Expect stools to be dark in color
• C. Take the medication before bedtime
• D. Avoid foods high in vitamin C

Correct answer: B

Rationale: The correct answer is B: 'Expect stools to be dark in color.' Dark stools are a common side effect of iron supplementation due to the unabsorbed iron, and this is not a cause for concern. Choice A is incorrect because taking iron with milk can decrease its absorption due to calcium binding. Choice C is incorrect as there are no specific recommendations to take ferrous sulfate before bedtime. Choice D is also incorrect as vitamin C actually enhances iron absorption and should not be avoided.

4. The nurse is caring for a client who is 4 hours post-operative from abdominal surgery. The client is complaining of severe pain. What is the nurse's first action?

• A. Reassess the pain and its characteristics
• B. Administer prescribed pain medication
• C. Notify the surgeon
• D. Encourage the use of relaxation techniques

Correct answer: A

Rationale: The correct first action for the nurse to take when a post-operative client complains of severe pain is to reassess the pain and its characteristics. Reassessment is crucial to understand the nature and intensity of the pain, which will guide the nurse in providing appropriate interventions. Administering pain medication may be necessary but should only be done after reassessment to ensure the right medication and dose are given. Notifying the surgeon may be required in certain situations, but reassessment of pain should precede this action. Encouraging relaxation techniques is not the priority when a client is experiencing severe pain post-operatively.

5. 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.

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