Nursing Elites

1. A client with cirrhosis is receiving spironolactone. What electrolyte level should the nurse monitor closely?

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

Correct answer: A

Rationale: The correct answer is to monitor potassium levels. Spironolactone is a potassium-sparing diuretic, which means it helps the body retain potassium and excrete sodium. Monitoring potassium levels closely is essential because spironolactone can cause hyperkalemia (high potassium levels). Sodium levels are not typically affected by spironolactone. Calcium and magnesium levels are also not directly impacted by spironolactone, making choices B, C, and D incorrect.

2. After receiving hemodialysis, what is the nurse's priority assessment for a client with chronic kidney disease?

• A. Monitor the client's potassium level.
• B. Assess the client's blood pressure.
• C. Check the client's hemoglobin and hematocrit levels.
• D. Monitor for signs of infection.

Correct answer: A

Rationale: The correct answer is to monitor the client's potassium level. During hemodialysis, there is a risk of potassium shifting, which can lead to life-threatening arrhythmias if not properly managed. Assessing the potassium level is crucial to prevent complications. While assessing blood pressure, checking hemoglobin and hematocrit levels, and monitoring for signs of infection are important aspects of care for a client with chronic kidney disease, monitoring potassium levels takes precedence due to its immediate life-threatening potential post-dialysis.

3. A client with a history of deep vein thrombosis (DVT) is prescribed warfarin. Which laboratory value should the nurse monitor to assess the therapeutic effect of this medication?

• A. Platelet count
• B. Prothrombin time (PT)
• C. White blood cell count
• D. Hemoglobin level

Correct answer: B

Rationale: Prothrombin time (PT) is the correct laboratory value to monitor to assess the therapeutic effect of warfarin. Warfarin works by inhibiting clotting factors, and PT measures the time it takes for blood to clot. Monitoring PT helps ensure that the medication is working effectively to prevent clot formation without causing excessive bleeding. Platelet count (Choice A) is not specific to warfarin therapy and assesses the number of platelets in the blood. White blood cell count (Choice C) and hemoglobin level (Choice D) are not directly related to monitoring the therapeutic effect of warfarin.

4. The nurse is caring for a client with acute pancreatitis who is reporting severe abdominal pain. Which nursing intervention should the nurse implement first?

• A. Assess the client's bowel sounds
• B. Administer prescribed pain medication
• C. Encourage the client to sit upright
• D. Provide clear fluids to the client

Correct answer: B

Rationale: In a client with acute pancreatitis experiencing severe abdominal pain, the priority nursing intervention is to provide pain relief. Administering prescribed pain medication is essential to improve comfort and reduce pain, which can help stabilize the client's condition. Assessing bowel sounds (Choice A) may be necessary but is not the immediate priority over pain management. Encouraging the client to sit upright (Choice C) and providing clear fluids (Choice D) are not the primary interventions for addressing severe abdominal pain in acute pancreatitis.

5. A client with chronic obstructive pulmonary disease (COPD) is being discharged home. What should the nurse include in the discharge teaching?

• A. Limit fluid intake to prevent lung congestion
• B. Avoid all physical activity to conserve energy
• C. Perform pursed-lip breathing during activities
• D. Increase oxygen flow rate if shortness of breath occurs

Correct answer: C

Rationale: The correct answer is C. Pursed-lip breathing helps control breathing and improves oxygen exchange in clients with COPD. It can ease shortness of breath during activities and should be included in discharge teaching to manage symptoms. Option A is incorrect as adequate fluid intake is important for thinning mucus in COPD. Option B is wrong as physical activity, as tolerated, is beneficial for COPD patients. Option D is also incorrect because changing oxygen flow rate without healthcare provider guidance can be dangerous.

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