Nursing Elites

1. The healthcare provider is caring for a client with jaundice. Which serum laboratory value is likely to be elevated for this client?

• A. Amylase
• B. Creatinine
• C. Blood urea nitrogen
• D. Bilirubin

Correct answer: D

Rationale: Bilirubin is a key serum laboratory value that is likely to be elevated in clients with jaundice. Jaundice is characterized by a yellowish discoloration of the skin and eyes due to an excess of bilirubin, a breakdown product of hemoglobin. Elevated amylase levels are associated with pancreatic conditions, not specifically jaundice. Creatinine and blood urea nitrogen are markers of kidney function and are not directly related to jaundice.

2. The nurse is caring for a client who is 2 days post-op following an abdominal hysterectomy. The client reports feeling something 'give way' in the incision site and there is a small amount of bowel protruding from the wound. What action should the nurse take first?

• A. Apply a sterile saline dressing to the wound
• B. Notify the healthcare provider
• C. Administer pain medication
• D. Cover the wound with an abdominal binder

Correct answer: A

Rationale: In this situation, the priority action for the nurse is to apply a sterile saline dressing to the wound. This helps to cover and protect the exposed bowel, preventing infection and maintaining a moist environment for wound healing. Option B, notifying the healthcare provider, is important but should come after addressing the immediate need of covering the wound. Administering pain medication (option C) and covering the wound with an abdominal binder (option D) are not appropriate initial actions for this situation.

3. A client diagnosed with tuberculosis (TB) is placed on drug therapy with rifampin (Rifadin). The client should be instructed to report which effect(s) of the medication to the healthcare provider?

• A. Reddish-orange discoloration of body fluids
• B. Bloody or blood-tinged urine
• C. Blurring of vision
• D. Weight gain of more than 2 pounds in a week

Correct answer: A

Rationale: The correct answer is A. Rifampin (Rifadin) commonly causes a reddish-orange discoloration of body fluids, including urine, sweat, saliva, and tears. This is a harmless side effect but should be reported to the healthcare provider for monitoring. Choices B, C, and D are not typically associated with rifampin therapy. Bloody or blood-tinged urine may indicate other issues such as urinary tract infection or kidney problems, blurring of vision may suggest eye problems, and significant weight gain could be related to various health conditions unrelated to rifampin.

4. A 7-year-old with cystic fibrosis (CF) has received instructions about home care. Which statement made by the child's mother indicates that further teaching is needed?

• A. My child should not have a cough at all times
• B. He needs to take pancreatic enzymes with meals and snacks
• C. He needs to use a bronchodilator every day
• D. His dietary intake needs to be high in protein and calories

Correct answer: A

Rationale: The correct answer is A. A cough at all times is not normal in a child with cystic fibrosis (CF) and indicates the need for further teaching on CF management. Choices B, C, and D are correct statements in managing CF: taking pancreatic enzymes with meals and snacks, using a bronchodilator daily, and maintaining a high-protein and high-calorie dietary intake are all appropriate for a child with CF.

5. A client in acute renal failure has a serum potassium of 7.5 mEq/L. Based on this finding, the nurse should anticipate implementing which action?

• A. Administer an IV of normal saline rapidly and NPH insulin subcutaneously.
• B. Administer a retention enema of Kayexalate.
• C. Add 40 mEq of KCL (potassium chloride) to the present IV solution.
• D. Administer a lidocaine bolus IV push.

Correct answer: B

Rationale: In acute renal failure with a high serum potassium level, the priority intervention is to lower potassium levels to prevent complications like cardiac arrhythmias. Administering a retention enema of Kayexalate is the correct action as it helps lower high potassium levels by exchanging sodium for potassium in the intestines. Options A, C, and D are incorrect. Administering normal saline rapidly and NPH insulin or adding more potassium to the IV solution can further increase potassium levels, worsening the condition. Lidocaine is not indicated for treating hyperkalemia.

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