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. The nurse is in charge of a Nursing unit in a long-term care facility. Which task is best for the nurse to assign to an unlicensed assistive personnel (UAP) who is helping with the care of several clients?

• A. Measure the amount of a client's residual urine after voiding
• B. Cleanse the perineal area of a client with urinary incontinence
• C. Insert a straight catheter to obtain a urine specimen for culture
• D. Provide catheter care for a client with a suprapubic catheter

Correct answer: B

Rationale: The correct answer is B because cleaning the perineal area is a task within the scope of practice for unlicensed assistive personnel (UAPs) and is crucial for preventing infections. Choice A involves a more complex task that requires a healthcare provider's assessment. Choice C involves a sterile procedure that should be performed by licensed staff. Choice D involves specific care for a client with a catheter that exceeds the UAP's scope of practice.

3. The client with a new colostomy is being taught about colostomy care. Which statement by the client indicates effective learning?

• A. I will change my colostomy bag every day.
• B. I should eat a low-fiber diet.
• C. I need to inspect the stoma daily for color and swelling.
• D. I can skip my colostomy care if I feel well.

Correct answer: C

Rationale: The correct answer is C because inspecting the stoma daily is crucial in identifying any early signs of complications or infections. Choice A is incorrect because changing the colostomy bag daily is not necessary unless there is a specific reason to do so. Choice B is incorrect as a low-fiber diet is not usually recommended for colostomy care. Choice D is incorrect because colostomy care should be performed regularly regardless of how the client feels.

4. The nurse is teaching a client about the administration of a subcutaneous injection. Which site is most appropriate for this type of injection?

• A. Deltoid muscle
• B. Dorsogluteal muscle
• C. Ventrogluteal muscle
• D. Abdomen

Correct answer: D

Rationale: The abdomen is a common site for subcutaneous injections due to its accessibility and ample subcutaneous tissue. Subcutaneous injections are typically given in areas with a layer of fat between the skin and muscle, such as the abdomen, to allow for slow and consistent absorption of the medication. The deltoid muscle is more appropriate for intramuscular injections, not subcutaneous. The dorsogluteal muscle and ventrogluteal muscle are also more suited for intramuscular injections, not subcutaneous.

5. What is the primary function of neutrophils?

• A. Heparin secretion
• B. Transport oxygen
• C. Phagocytotic action
• D. Antibody formation

Correct answer: C

Rationale: The correct answer is C: Phagocytotic action. Neutrophils are key components of the immune system, primarily involved in the phagocytosis of bacteria and other pathogens. Choice A, Heparin secretion, is incorrect as heparin is primarily secreted by mast cells and basophils. Choice B, Transport oxygen, is incorrect as this is mainly the function of red blood cells. Choice D, Antibody formation, is incorrect as antibody production is primarily carried out by B lymphocytes.

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