Nursing Elites

1. The healthcare provider is assessing a client with left-sided heart failure. Which laboratory value should be closely monitored?

• A. Serum sodium level
• B. Serum potassium level
• C. Serum creatinine level
• D. Serum glucose level

Correct answer: B

Rationale: In a client with left-sided heart failure, monitoring serum potassium levels is crucial. This helps in assessing kidney function and fluid balance. Elevated potassium levels can result from impaired kidney function, which is common in heart failure. Monitoring sodium levels (choice A) is important in heart failure but not specifically related to left-sided heart failure. Serum creatinine (choice C) reflects kidney function but is not the most critical value to monitor in this case. Serum glucose level (choice D) is important but not the priority when assessing left-sided heart failure.

2. The client with end-stage renal disease (ESRD) is scheduled for hemodialysis. Which laboratory value is most concerning?

• A. Serum potassium of 6.0 mEq/L
• B. Serum creatinine of 2.5 mg/dL
• C. Serum calcium of 8.0 mg/dL
• D. Hemoglobin of 10 g/dL

Correct answer: A

Rationale: A serum potassium level of 6.0 mEq/L is most concerning in a client with ESRD scheduled for hemodialysis as it indicates hyperkalemia, which can lead to serious cardiac complications such as arrhythmias and cardiac arrest. Immediate intervention is required to lower potassium levels. Choice B, serum creatinine of 2.5 mg/dL, is elevated but expected in ESRD due to impaired kidney function. Choice C, serum calcium of 8.0 mg/dL, is within the normal range and not typically a priority in this situation. Choice D, hemoglobin of 10 g/dL, is slightly low but not an immediate concern for a client scheduled for hemodialysis unless significantly lower and causing severe symptoms.

3. A client with a traumatic brain injury becomes progressively less responsive to stimuli. The client has a 'Do Not Resuscitate' prescription, and the nurse observes that the unlicensed assistive personnel (UAP) has stopped turning the client from side to side as previously scheduled. What action should the nurse take?

• A. Advise the UAP to resume positioning the client on schedule
• B. Notify the healthcare provider
• C. Document the UAP's actions
• D. Discuss the situation with the client’s family

Correct answer: A

Rationale: Continuing to turn the client is crucial to prevent complications such as pressure ulcers, even if the client is less responsive. Advising the UAP to resume positioning the client on schedule is the most appropriate action in this situation. This action ensures that the client's care needs are met and helps prevent potential complications. Notifying the healthcare provider or documenting the UAP's actions may delay the necessary care for the client. Discussing the situation with the client's family is important but addressing the immediate care need of turning the client takes priority.

4. The nurse is assessing a client with a small bowel obstruction who was hospitalized 24 hours ago. Which assessment finding should the nurse report immediately to the healthcare provider?

• A. Hypoactive bowel sounds in the lower quadrant.
• B. Rebound tenderness in the upper quadrants.
• C. Tympany with percussion of the abdomen.
• D. Light-colored gastric aspirate via the nasogastric tube.

Correct answer: B

Rationale: Rebound tenderness in the upper quadrants may indicate peritonitis, which requires prompt medical attention. Hypoactive bowel sounds are expected in small bowel obstruction and would not be a priority over signs of peritonitis. Tympany with percussion is a normal finding and not a cause for immediate concern. Light-colored gastric aspirate could indicate various issues but is not as urgent as peritonitis.

5. The nurse is triaging several children as they present to the emergency room after an accident. Which child requires the most immediate intervention by the nurse?

• A. An 11-year-old with a headache, nausea, and projectile vomiting
• B. A 5-year-old with a broken arm
• C. A 7-year-old with minor abrasions
• D. A 9-year-old with a twisted ankle

Correct answer: A

Rationale: The correct answer is A. Projectile vomiting in a child with a headache could indicate increased intracranial pressure, requiring immediate attention. Choices B, C, and D do not present with symptoms indicating potentially life-threatening conditions that require urgent intervention.

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