Nursing Elites

1. A nurse is caring for a client who has a prescription for spironolactone. Which of the following laboratory values should the nurse monitor?

• A. Sodium 140 mEq/L
• B. Calcium 9.5 mg/dL
• C. Potassium 5.2 mEq/L
• D. Magnesium 2.0 mEq/L

Correct answer: C

Rationale: The correct answer is C: Potassium 5.2 mEq/L. A potassium level of 5.2 mEq/L is elevated and should be monitored in clients taking spironolactone, which is a potassium-sparing medication. Monitoring potassium levels is crucial as spironolactone can cause hyperkalemia. Choices A, B, and D are incorrect because sodium, calcium, and magnesium levels are not typically affected by spironolactone. Therefore, the nurse should primarily focus on monitoring the potassium levels in this scenario.

2. If a nurse administers an incorrect dose of medication, which fact related to the incident report should the nurse document in the client's medical record?

• A. Time the medication was given
• B. The client's response to the medication
• C. The dose that was administered
• D. Reason for the error

Correct answer: A

Rationale: The correct answer is to document the time the medication was given. This is essential for understanding the sequence of events surrounding the medication error. While documenting the client's response to the medication (Choice B) is important for assessing any effects, the immediate concern should be to establish a clear timeline by documenting the time of administration. Recording the dose administered (Choice C) is also important, but in the context of understanding the incident, the time factor takes precedence. The reason for the error (Choice D) should be included in the incident report but may not be the first priority when documenting in the client's medical record.

3. A client with a new diagnosis of type 1 diabetes mellitus is being taught by a nurse about insulin administration. Which of the following instructions should the nurse include?

• A. Store unopened vials of insulin in the refrigerator, not the freezer.
• B. Rotate injection sites within the same region to prevent tissue damage.
• C. Administer insulin at a 90-degree angle for subcutaneous injections.
• D. Avoid massaging the injection site after administering insulin.

Correct answer: B

Rationale: The correct answer is to rotate injection sites within the same region to prevent tissue damage. By rotating sites, the client can prevent lipodystrophy, which is a condition characterized by the loss or change in body fat at the site of repeated injections. This practice also helps to ensure proper insulin absorption. Storing unopened vials of insulin in the refrigerator (Choice A) is correct, not in the freezer, as freezing can damage the insulin. Administering insulin at a 90-degree angle (Choice C) is more appropriate for subcutaneous injections, while a 45-degree angle is used for intramuscular injections. Massaging the injection site after administering insulin (Choice D) is not recommended as it can affect insulin absorption rates.

4. A client with multiple sclerosis and dysphagia requires care. Which intervention should the nurse include in the plan?

• A. Position the client supine with the head of the bed flat.
• B. Have the client tuck their chin while swallowing.
• C. Provide the client with thickened liquids.
• D. Place the food on the unaffected side of the mouth.

Correct answer: C

Rationale: For clients with dysphagia, especially those with multiple sclerosis, thin liquids can increase the risk of aspiration. Thickened liquids are recommended to reduce the risk of aspiration and help with swallowing difficulties. Positioning the client supine with the head of the bed flat can further increase the risk of aspiration. Having the client tuck their chin while swallowing is a strategy used for some types of dysphagia but not specifically for multiple sclerosis-related dysphagia. Placing food on the unaffected side of the mouth does not address the swallowing difficulties associated with dysphagia.

5. A healthcare provider is performing a skin assessment for a client and observes several skin lesions. Which of the following findings is a priority to report to the provider?

• A. Raised nevus
• B. Macule
• C. Vesicle
• D. Irregularly shaped mole

Correct answer: D

Rationale: An irregularly shaped mole is a priority finding to report to the provider as it can be indicative of melanoma, a type of skin cancer. Melanoma is a serious condition that requires prompt evaluation and treatment. Raised nevus, macule, and vesicle are common skin findings that are typically benign and may not require immediate attention. Therefore, the irregularly shaped mole stands out as the priority due to its association with potential malignancy.

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