Nursing Elites

1. A client with a history of hypertension is prescribed a diuretic. Which of the following laboratory values should the nurse monitor to evaluate the effectiveness of the medication?

• A. Monitor serum calcium levels.
• B. Monitor serum potassium levels.
• C. Monitor serum sodium levels.
• D. Monitor serum magnesium levels.

Correct answer: B

Rationale: The correct answer is to monitor serum potassium levels. When a client is prescribed a diuretic, monitoring serum potassium levels is essential to evaluate the medication's effectiveness and to detect potential electrolyte imbalances. Diuretics can cause potassium loss, leading to hypokalemia, which can have serious consequences such as cardiac arrhythmias. Monitoring serum calcium levels (Choice A) is not typically required when assessing the effectiveness of diuretics. Similarly, monitoring serum sodium levels (Choice C) is important for other conditions but is not the primary concern when evaluating diuretic therapy. Monitoring serum magnesium levels (Choice D) is also important, but potassium levels are more critical in assessing diuretic effectiveness and preventing complications.

2. A client is being treated for pneumonia and is receiving intravenous antibiotics. The nurse notes that the client has developed a rash and is complaining of itching. Which of the following is the most appropriate initial nursing action?

• A. Administer diphenhydramine (Benadryl)
• B. Discontinue the antibiotic infusion
• C. Apply a cool compress to the rash
• D. Notify the healthcare provider

Correct answer: B

Rationale: The most appropriate initial nursing action when a client develops a rash and itching while receiving intravenous antibiotics is to discontinue the antibiotic infusion. This is crucial to prevent further allergic reactions. Administering diphenhydramine (Benadryl) (Choice A) can be considered after discontinuing the antibiotic infusion. Applying a cool compress to the rash (Choice C) may provide symptomatic relief but does not address the underlying cause. Notifying the healthcare provider (Choice D) is important but should come after discontinuing the antibiotic infusion to ensure the client's safety.

3. A client is experiencing dyspnea and fatigue after completing morning care. Which of the following actions should the nurse include in the client’s plan of care?

• A. Schedule rest periods during morning care.
• B. Discontinue morning care for 2 days.
• C. Perform all care as quickly as possible.
• D. Ask a family member to come in to bathe the client.

Correct answer: A

Rationale: Scheduling rest periods during morning care is essential for managing dyspnea and fatigue in the client. This approach allows the client to pace themselves and catch their breath, promoting comfort and reducing symptoms. It is crucial to provide breaks to prevent overwhelming the client and exacerbating their symptoms. Discontinuing morning care for 2 days (choice B) is not a suitable solution as it does not address the underlying issue and may lead to neglect of essential care. Performing all care as quickly as possible (choice C) can worsen the client's symptoms and compromise their well-being by increasing stress and exertion. Asking a family member to bathe the client (choice D) does not address the need for rest periods during care and may not be feasible or appropriate in all situations.

4. While caring for a client who begins to experience a generalized seizure while standing in her room, which of the following actions should the nurse take?

• A. Place a pad under the client’s head
• B. Hold the client’s limbs tightly to prevent injury
• C. Lift the client into bed with the help of other staff members
• D. Insert a bite block into the client’s mouth

Correct answer: A

Rationale: During a seizure, the priority is to protect the client's head and ensure their safety. The nurse should guide the client to the ground if possible and place a soft pad or a folded cloth under the head to prevent injury. Restraining the client's limbs can result in injury and should be avoided. Lifting the client can also lead to injuries during a seizure. Inserting a bite block is contraindicated as it can cause damage to the teeth, oral tissues, and obstruct the airway. Therefore, the correct action is to place a pad under the client's head to protect them during the seizure.

5. An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the LPN/LVN implement first?

• A. Reaffirm the client's desire for no resuscitative efforts.
• B. Transfer the client to a hospice inpatient facility.
• C. Prepare the family for the client's impending death.
• D. Notify the healthcare provider of the family's request.

Correct answer: D

Rationale: The first action the LPN/LVN should implement is to notify the healthcare provider of the family's request. This is crucial to ensure that appropriate steps are taken to address the family's request for hospice care and to coordinate the necessary care for the resident. While reaffirming the client's desire for no resuscitative efforts is important, notifying the healthcare provider takes precedence in this situation. Transferring the client to a hospice inpatient facility and preparing the family for the client's impending death are significant actions but should be done after notifying the healthcare provider to ensure proper coordination of care.

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