Nursing Elites

1. A client with heart failure is prescribed furosemide. What finding should the nurse report to the provider?

• A. Sodium 140 mEq/L
• B. Heart rate of 82/min
• C. Potassium level of 2.8 mEq/L
• D. Oxygen saturation 95%

Correct answer: C

Rationale: The correct answer is C. A potassium level of 2.8 mEq/L is low and should be reported to the provider. Furosemide can cause potassium depletion, leading to hypokalemia. Low potassium levels can result in cardiac dysrhythmias, which is a serious concern in clients with heart failure. Choices A, B, and D are within normal ranges and do not require immediate reporting. Sodium level of 140 mEq/L, heart rate of 82/min, and oxygen saturation of 95% are all acceptable findings.

2. A nurse is caring for a client who has cirrhosis. Which of the following laboratory values should the nurse expect to be elevated?

• A. Serum albumin.
• B. Ammonia.
• C. Bilirubin.
• D. Prothrombin time.

Correct answer: B

Rationale: The correct answer is B: Ammonia. In clients with cirrhosis, impaired liver function can lead to elevated levels of ammonia in the blood. Elevated ammonia levels can result in hepatic encephalopathy, a condition characterized by altered mental status. Serum albumin (Choice A) is typically decreased in cirrhosis due to the liver's reduced synthetic function. Bilirubin (Choice C) levels can be elevated in liver disease but may not always be the most specific marker for cirrhosis. Prothrombin time (Choice D) is prolonged in cirrhosis due to impaired liver synthesis of clotting factors.

3. What is the appropriate action when a patient presents with chest pain?

• A. Administer aspirin
• B. Administer nitroglycerin
• C. Reposition the patient
• D. Prepare for surgery

Correct answer: A

Rationale: The appropriate action when a patient presents with chest pain is to administer aspirin. Aspirin helps reduce the risk of clot formation by inhibiting platelet aggregation, which can be beneficial in cases of myocardial infarction. Nitroglycerin is commonly used for chest pain related to angina but is not the first-line treatment for all types of chest pain. Repositioning the patient may be necessary for comfort or assessment but is not the immediate priority. Surgery is not typically the first-line intervention for chest pain unless there are specific indications.

4. What is the most appropriate action when a patient is experiencing severe dehydration?

• A. Administer IV fluids
• B. Encourage oral fluids
• C. Monitor electrolytes
• D. Perform a neurological exam

Correct answer: A

Rationale: The most appropriate action when a patient is experiencing severe dehydration is to administer IV fluids. This intervention is crucial in rapidly correcting dehydration and restoring fluid balance. Encouraging oral fluids may not be sufficient in cases of severe dehydration where intravenous rehydration is needed. Monitoring electrolytes is important but administering fluids takes precedence in severe dehydration. Performing a neurological exam is not the primary intervention for severe dehydration.

5. A healthcare professional is preparing to administer packed red blood cells (PRBCs) to a client. Which of the following actions should the healthcare professional take?

• A. Infuse the PRBCs over 8 hours.
• B. Verify the client's blood type and Rh factor.
• C. Administer the PRBCs through a 24-gauge catheter.
• D. Administer the PRBCs with lactated Ringer's solution.

Correct answer: B

Rationale: Verifying the client's blood type and Rh factor is crucial before administering blood products to ensure compatibility and prevent adverse reactions. Option A is incorrect because PRBCs are typically infused over a specific time frame based on hospital policy and client condition, not necessarily over 8 hours. Option C is incorrect as PRBCs are usually administered through a larger gauge catheter to prevent hemolysis. Option D is incorrect because PRBCs are typically administered with normal saline and not lactated Ringer's solution.

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