Nursing Elites

1. A nurse is caring for a client who has chronic kidney disease and reports nausea. The nurse should identify that this client is at risk for which of the following imbalances?

• A. Metabolic alkalosis
• B. Metabolic acidosis
• C. Respiratory alkalosis
• D. Respiratory acidosis

Correct answer: B

Rationale: The correct answer is B: Metabolic acidosis. Clients with chronic kidney disease are at risk for metabolic acidosis because the kidneys are unable to effectively excrete acids, leading to an accumulation of acid in the body. This metabolic imbalance can result in symptoms like nausea. Choices A, C, and D are incorrect. Metabolic alkalosis is not typically associated with chronic kidney disease. Respiratory alkalosis is more commonly seen in conditions such as hyperventilation. Respiratory acidosis, on the other hand, is often linked to conditions affecting the lungs or respiratory system, not primarily kidney disease.

2. A nurse in the PACU is caring for a client who reports nausea. Which of the following actions should the nurse take first?

• A. Turn the client on their side.
• B. Administer an analgesic.
• C. Administer antiemetic.
• D. Monitor the client's vital signs.

Correct answer: A

Rationale: The correct action the nurse should take first when a client reports nausea in the PACU is to turn the client on their side. This action helps prevent aspiration in a client with nausea, reducing the risk of choking or inhaling vomitus. Administering an analgesic (Choice B) is not the priority in this situation unless pain is the primary cause of nausea. While administering an antiemetic (Choice C) can help relieve nausea, it is not the initial action to prevent aspiration. Monitoring the client's vital signs (Choice D) is important but should come after ensuring the client's safety by turning them on their side.

3. What is the initial action a healthcare provider should take for a patient with chest pain?

• A. Administer oxygen
• B. Administer nitroglycerin
• C. Administer morphine
• D. Prepare for surgery

Correct answer: A

Rationale: The correct initial action for a patient with chest pain is to administer oxygen. Chest pain can be caused by insufficient oxygenation, and providing oxygen helps alleviate the pain by increasing oxygen levels in the blood. Administering nitroglycerin or morphine may be appropriate based on the underlying cause of the chest pain, but oxygen should be given first to ensure the patient's oxygen supply is adequate. Surgery is not typically the initial intervention for chest pain.

4. A nurse is reviewing the medical record of a client who has a prescription for spironolactone. Which of the following findings should the nurse report to the provider?

• A. Potassium 5.0 mEq/L
• B. Blood pressure 136/84 mm Hg
• C. Sodium 140 mEq/L
• D. Calcium 9.5 mg/dL

Correct answer: A

Rationale: A potassium level of 5.0 mEq/L is at the upper limit of normal and should be monitored closely in clients taking spironolactone, which is potassium-sparing. Elevated potassium levels can lead to hyperkalemia, especially in individuals on potassium-sparing diuretics like spironolactone. Monitoring and reporting high potassium levels are crucial to prevent potential complications such as cardiac arrhythmias. Blood pressure (choice B), sodium level (choice C), and calcium level (choice D) are not directly related to the use of spironolactone and do not require immediate reporting in this scenario.

5. A client who has a new diagnosis of type 2 diabetes mellitus is being taught about foot care by a nurse. Which of the following statements should the nurse include?

• A. Use lotion on your feet to prevent dry, cracked skin, avoiding application between the toes.
• B. Avoid soaking your feet in warm water daily to prevent dry skin.
• C. Trim your toenails straight across to prevent injury.
• D. Do not apply a heating pad to your feet if they feel cold.

Correct answer: C

Rationale: The correct answer is C. Trimming toenails straight across is essential for clients with diabetes to prevent the risk of ingrown toenails and injury. Using lotion on feet can be beneficial but should not be applied between the toes to avoid moisture buildup, which can lead to infections. Soaking feet in warm water can lead to dry skin, increasing the risk of cracks and other complications. Applying a heating pad to feet when they feel cold is not recommended for clients with diabetes due to impaired sensation, which can result in burns and other injuries.

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