Nursing Elites

1. The client with liver cirrhosis needs immediate intervention for which abnormal laboratory result?

• A. Prothrombin time (PT) of 14 seconds.
• B. Bilirubin of 1.2 mg/dL.
• C. Albumin of 4 g/dL.
• D. Ammonia level of 80 mcg/dL.

Correct answer: D

Rationale: An elevated ammonia level of 80 mcg/dL indicates hepatic encephalopathy, a serious complication of liver cirrhosis that requires immediate intervention. Ammonia is a neurotoxin that accumulates in the blood due to impaired liver function, leading to cognitive impairment and altered mental status. Monitoring and lowering ammonia levels are crucial in managing hepatic encephalopathy to prevent further neurological deterioration. Prothrombin time, bilirubin, and albumin levels are important parameters in assessing liver function and overall health status in clients with liver cirrhosis, but an elevated ammonia level poses an immediate threat to neurological function and warrants prompt attention.

2. A client who is taking clonidine (Catapres, Duraclon) reports drowsiness. Which additional assessment should the nurse make?

• A. How long has the client been taking the medication?
• B. Assess the client's dietary habits.
• C. Check for signs of infection.
• D. Evaluate the client's sleep pattern.

Correct answer: A

Rationale: The correct answer is A. When a client reports drowsiness while taking clonidine, the nurse should assess how long the client has been taking the medication. Drowsiness is a common side effect that can occur in the early weeks of treatment with clonidine. By understanding the duration of medication use, the nurse can determine if the drowsiness is a temporary effect that may decrease over time. Choices B, C, and D are incorrect because assessing the client's dietary habits, checking for signs of infection, or evaluating the client's sleep pattern would not directly address the drowsiness associated with clonidine use.

3. The home health nurse visits a young male client with AIDS who has Kaposi's sarcoma and peripheral neuropathies. His parents, who are the caregivers, tell the nurse that their son sleeps most of the time. The nurse assesses that the client is semi-conscious with stable vital signs, cries out in pain when turned or moved, has a Duragesic pain patch in place, and skin lesions that are closed and dried. Which intervention should the nurse implement?

• A. remove the Duragesic patch as directed by the prescription
• B. give the client a complete bed bath to further assess the client's condition
• C. discuss end-of-life decisions with the client's parents
• D. call for ambulance transportation to the hospital immediately

Correct answer: C

Rationale: In this scenario, the client with AIDS is showing signs of being in a critical condition - semi-conscious, in pain, and with stable vital signs. The appropriate intervention for the nurse to implement is to discuss end-of-life decisions with the client's parents. Given the client's symptoms, the presence of a pain patch, and the closed and dried skin lesions, it is essential to address end-of-life care planning. Removing the Duragesic patch without proper authorization can lead to inadequate pain management and should not be done without consulting the healthcare provider. Giving a complete bed bath is not the priority in this situation as it does not address the immediate needs of the client. Calling for ambulance transportation to the hospital immediately may not be necessary if the client is stable; instead, the focus should be on providing appropriate support and having critical discussions about the client's care preferences.

4. The healthcare provider is assessing a client who has returned from surgery. Which finding requires immediate intervention?

• A. Heart rate of 90 beats per minute.
• B. Oxygen saturation of 92%.
• C. Temperature of 99°F (37.2°C).
• D. Pain at the surgical site.

Correct answer: C

Rationale: A temperature of 99°F (37.2°C) in a postoperative client requires immediate intervention as it may indicate the presence of infection. Elevated temperature post-surgery can be a sign of surgical site infection or systemic infection, which can lead to serious complications if not addressed promptly. Monitoring and managing a fever in a postoperative client is crucial to prevent further complications. The other findings, such as a heart rate of 90 beats per minute, oxygen saturation of 92%, and pain at the surgical site, are common postoperative assessments that may not necessarily require immediate intervention unless they are significantly out of normal range or causing severe distress to the client.

5. The healthcare professional is conducting a community assessment to identify health needs. Which method is most effective for gathering comprehensive data?

• A. conducting focus groups with community members
• B. reviewing local health department reports
• C. surveying healthcare providers in the area
• D. analyzing hospital admission records

Correct answer: A

Rationale: Conducting focus groups with community members is the most effective method for gathering comprehensive data during a community assessment. This approach allows direct interaction with community members, fostering in-depth discussions that provide insights into the specific health needs and concerns of the community. Choice B, reviewing local health department reports, may offer valuable data but might not capture the nuanced perspectives and experiences of community members. Choice C, surveying healthcare providers, provides insights from a professional standpoint but may not fully represent the community's diverse health needs. Choice D, analyzing hospital admission records, offers information on healthcare utilization but may overlook important social determinants of health and community-specific issues that can only be addressed through direct engagement with community members.

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