Nursing Elites

1. The nurse is caring for a client with acute pancreatitis who is receiving total parenteral nutrition (TPN). Which laboratory value should be monitored closely?

• A. Serum calcium
• B. Serum triglycerides
• C. Serum glucose
• D. Serum triglycerides

Correct answer: B

Rationale: Serum triglycerides should be monitored closely in a client receiving TPN as they may indicate hyperlipidemia, which is a potential complication of TPN. Monitoring serum triglycerides is essential to prevent complications such as hypertriglyceridemia. Serum calcium and glucose levels are also important to monitor in clients receiving TPN, but in this scenario, serum triglycerides take priority due to the risk of hyperlipidemia.

2. A client with acute pancreatitis is admitted with severe abdominal pain. Which assessment finding requires immediate intervention?

• A. Severe abdominal distention
• B. Decreased urine output
• C. Decreased bowel sounds
• D. Increased heart rate

Correct answer: A

Rationale: Severe abdominal distention is a sign of worsening pancreatitis and can indicate complications like bowel obstruction or fluid accumulation. Immediate intervention is necessary to prevent further deterioration. Decreased urine output (Choice B) could indicate renal impairment, decreased bowel sounds (Choice C) are expected in pancreatitis due to paralytic ileus, and an increased heart rate (Choice D) is a common response to pain or stress in acute pancreatitis but may not require immediate intervention unless it is extremely high or persistent.

3. The nurse is caring for a 17-year-old male who fell 20 feet 5 months ago while climbing the side of a cliff and has been in a sustained vegetative state since the accident. Which intervention should the nurse implement?

• A. Talk directly to the adolescent while providing care
• B. Maintain silence during care to avoid overstimulation
• C. Play soothing music in the background
• D. Limit visitors to immediate family only

Correct answer: A

Rationale: Talking directly to the adolescent is the most appropriate intervention in this scenario. It helps maintain a sense of connection and respect, even if the response is not evident. Maintaining silence may lead to isolation and hinder any potential communication attempts. Playing soothing music may not provide the personal interaction needed for connection. Limiting visitors to immediate family only may deprive the patient of diverse interactions that could be beneficial for their emotional well-being.

4. A client with chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Which assessment finding is most concerning?

• A. Oxygen saturation of 90%
• B. Respiratory rate of 24 breaths per minute
• C. Use of accessory muscles
• D. Inspiratory crackles

Correct answer: C

Rationale: The correct answer is C: 'Use of accessory muscles.' In a client with COPD and pneumonia, the use of accessory muscles indicates increased work of breathing. This finding is concerning as it may signal respiratory failure, requiring immediate intervention. Oxygen saturation of 90% (choice A) is low but not as immediately concerning as the increased work of breathing. A respiratory rate of 24 breaths per minute (choice B) is slightly elevated but not as critical as the use of accessory muscles. Inspiratory crackles (choice D) may be present in pneumonia but are not as indicative of impending respiratory failure as the increased work of breathing shown by the use of accessory muscles.

5. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which assessment finding requires immediate intervention?

• A. Use of accessory muscles
• B. Oxygen saturation of 90%
• C. Respiratory rate of 24 breaths per minute
• D. Blood pressure of 110/70 mmHg

Correct answer: A

Rationale: The correct answer is A: Use of accessory muscles. This finding indicates increased work of breathing in a client with COPD and may signal respiratory failure, requiring immediate intervention. In COPD, the use of accessory muscles suggests that the client is in distress and struggling to breathe effectively. Oxygen saturation of 90% is within an acceptable range for a client with COPD receiving supplemental oxygen and does not require immediate intervention. A respiratory rate of 24 breaths per minute is slightly elevated but not a critical finding. A blood pressure of 110/70 mmHg is within the normal range for an adult and does not indicate a need for immediate intervention in this scenario.

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