Nursing Elites

1. A nurse is caring for a client who has chronic kidney disease and a serum potassium level of 6.0 mEq/L. Which of the following findings should the nurse expect?

• A. Hypokalemia
• B. Hypocalcemia
• C. Hypoglycemia
• D. Hyperkalemia

Correct answer: D

Rationale: The correct answer is D: Hyperkalemia. In chronic kidney disease, there is decreased renal excretion of potassium, leading to elevated serum potassium levels. Hypokalemia (Choice A) is low potassium levels, which is the opposite finding in this scenario. Hypocalcemia (Choice B) is decreased calcium levels and is not directly related to chronic kidney disease or elevated potassium levels. Hypoglycemia (Choice C) is low blood sugar levels and is not typically associated with chronic kidney disease or high potassium levels.

2. A nurse is caring for a client who is 36 weeks gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?

• A. Proteinuria of 1+.
• B. Blood pressure 120/80 mm Hg.
• C. Respiratory rate of 18/min.
• D. Nonpitting ankle edema.

Correct answer: D

Rationale: Nonpitting ankle edema is a concerning sign of worsening preeclampsia due to fluid retention and should be reported immediately. Proteinuria of 1+ is a common finding in preeclampsia. A blood pressure of 120/80 mm Hg is within normal limits. A respiratory rate of 18/min is also within normal range. Therefore, choices A, B, and C are not as urgent as nonpitting ankle edema in this scenario.

3. A nurse is developing a care plan for a client with Alzheimer's disease. Which of the following interventions should the nurse include?

• A. Provide reality orientation throughout the day.
• B. Limit the client's choices to prevent decision fatigue.
• C. Encourage the client to participate in group therapy.
• D. Engage the client in sensory stimulation activities.

Correct answer: A

Rationale: The correct intervention the nurse should include in the care plan for a client with Alzheimer's disease is to provide reality orientation throughout the day. Reality orientation involves helping clients with Alzheimer's disease stay connected to the present, reducing confusion and disorientation. This intervention can help the client maintain a sense of time, place, and person. Choices B, C, and D are incorrect because limiting choices may lead to frustration, group therapy may not always be suitable for clients with Alzheimer's disease, and sensory stimulation activities may not address the core issue of disorientation in Alzheimer's disease.

4. A nurse is caring for a client who is receiving enteral nutrition via a nasogastric tube. Which of the following actions should the nurse take to reduce the risk of aspiration?

• A. Position the client supine during feedings.
• B. Administer the feedings over 10 minutes.
• C. Elevate the head of the bed during feedings.
• D. Place the client in a lateral position after feedings.

Correct answer: C

Rationale: The correct action to reduce the risk of aspiration in clients receiving enteral feedings is to elevate the head of the bed during feedings. This position helps prevent regurgitation and aspiration of the feeding. Positioning the client supine (Choice A) increases the risk of aspiration as it promotes reflux. Administering feedings over 10 minutes (Choice B) does not directly reduce the risk of aspiration. Placing the client in a lateral position after feedings (Choice D) does not address the risk of aspiration during the feeding process.

5. A healthcare provider is planning to delegate client assignments to the assistive personnel. Which of the following tasks is appropriate for the healthcare provider to delegate?

• A. Adjusting the flow rate of the client's oxygen tank.
• B. Collecting a urine sample.
• C. Measuring the client's pain level.
• D. Transporting a client to x-ray.

Correct answer: D

Rationale: The correct answer is 'D: Transporting a client to x-ray.' This task is appropriate for delegation to assistive personnel as it involves transferring the client safely from one location to another, which does not require the specialized skills of a healthcare provider. Adjusting the flow rate of the client's oxygen tank (Choice A) involves making clinical decisions that should be done by a licensed healthcare provider. Collecting a urine sample (Choice B) and measuring the client's pain level (Choice C) require critical thinking and assessment skills that are typically within the scope of practice of licensed healthcare providers, not assistive personnel.

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