Nursing Elites

1. A client with a tracheostomy has thick, tenacious secretions. Which intervention should the nurse implement first?

• A. Perform deep suctioning every 2 to 4 hours.
• B. Encourage the client to drink plenty of fluids.
• C. Increase humidity in the client's room.
• D. Administer a mucolytic agent.

Correct answer: C

Rationale: Increasing humidity in the client's room can help liquefy thick secretions and facilitate easier airway clearance in a client with a tracheostomy. This intervention should be implemented first as it is non-invasive and can often effectively address the issue of thick secretions. Performing deep suctioning (Choice A) should not be the first intervention as it is more invasive and should be done based on assessment findings. Encouraging the client to drink plenty of fluids (Choice B) is beneficial but may not provide immediate relief for thick secretions. Administering a mucolytic agent (Choice D) requires a healthcare provider's prescription and should be based on assessment data and the client's condition.

2. A client with chronic heart failure is receiving furosemide (Lasix). Which laboratory value requires immediate intervention?

• A. Serum potassium of 3.0 mEq/L
• B. Serum sodium of 135 mEq/L
• C. Serum creatinine of 1.5 mg/dl
• D. Blood glucose of 200 mg/dl

Correct answer: A

Rationale: A serum potassium level of 3.0 mEq/L requires immediate intervention in a client receiving furosemide. Furosemide can cause potassium loss, leading to hypokalemia, which can be dangerous, especially in patients with heart failure. Hypokalemia can predispose the client to cardiac dysrhythmias, weakness, and other complications. Therefore, prompt intervention is necessary to prevent these adverse effects. Choice B (Serum sodium of 135 mEq/L) is within the normal range and does not require immediate intervention. Choice C (Serum creatinine of 1.5 mg/dl) may indicate kidney dysfunction but does not pose an immediate threat to the client's safety. Choice D (Blood glucose of 200 mg/dl) may suggest hyperglycemia, which is important but not as urgent as addressing hypokalemia in a client with heart failure receiving furosemide.

3. The healthcare provider prescribes atenolol 50 mg daily for a client with angina pectoris. Which finding should the nurse report to the healthcare provider before administering this medication?

• A. Irregular pulse.
• B. Tachycardia.
• C. Chest pain.
• D. Urinary frequency.

Correct answer: A

Rationale: The correct answer is A: Irregular pulse. An irregular pulse may indicate an arrhythmia, which could be exacerbated by atenolol, a beta-blocker used to treat angina pectoris. Atenolol works by slowing the heart rate, so if the patient already has an irregular pulse, it could worsen with the medication. Tachycardia (choice B) would actually be an expected finding in a patient with angina pectoris, and atenolol is used to help reduce the heart rate in such cases. Chest pain (choice C) is a symptom that atenolol is meant to alleviate, so it would not be a reason to withhold the medication. Urinary frequency (choice D) is not directly related to the administration of atenolol for angina pectoris and would not require immediate reporting to the healthcare provider.

4. The nurse is caring for a client with a history of atrial fibrillation who is receiving warfarin (Coumadin). Which laboratory value should be closely monitored?

• A. Serum potassium level
• B. Prothrombin time (PT)
• C. International Normalized Ratio (INR)
• D. Serum sodium level

Correct answer: C

Rationale: The correct answer is C, International Normalized Ratio (INR). The INR should be closely monitored in a client receiving warfarin (Coumadin) to assess the effectiveness and safety of anticoagulation therapy. Monitoring the INR helps ensure that the client is within the therapeutic range for anticoagulation to prevent complications such as bleeding or clotting. Choices A, B, and D are incorrect. While monitoring electrolyte levels like serum potassium and sodium is important in overall client care, they are not specific to monitoring the effects of warfarin therapy. Prothrombin time (PT) is a component of INR and helps in monitoring warfarin therapy, but INR gives a standardized result that is independent of the laboratory method used, making it the preferred choice for monitoring warfarin therapy.

5. An adult female client with chronic kidney disease (CKD) asks the nurse if she can continue taking over-the-counter medications. Which medication provides the greatest threat to this client?

• A. Magnesium hydroxide (Maalox).
• B. Birth control pills.
• C. Cough syrup containing codeine.
• D. Cold medication containing alcohol.

Correct answer: A

Rationale: The correct answer is A: Magnesium hydroxide (Maalox). In clients with CKD, magnesium can accumulate to toxic levels due to decreased excretion by the kidneys. Therefore, it poses the greatest threat to this client population. Choice B, birth control pills, is not typically contraindicated in CKD. Choice C, cough syrup containing codeine, may require dose adjustments but is not the greatest threat. Choice D, cold medication containing alcohol, is a concern mainly in liver disease, not CKD.

Similar Questions