Nursing Elites

1. A client has hypertension and a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take?

• A. Suggest that the client use a salt substitute
• B. Obtain a 12-lead ECG
• C. Obtain a blood sample for a serum sodium level
• D. Advise the client to add citrus juices and bananas to their diet

Correct answer: B

Rationale: Obtaining a 12-lead ECG is crucial in this situation to assess cardiac function due to the elevated potassium level. High potassium levels can lead to dangerous arrhythmias, and an ECG helps in detecting any cardiac abnormalities. Choices A, C, and D are incorrect. Suggesting a salt substitute can further elevate the client's potassium levels. Checking serum sodium levels is not the priority when dealing with high potassium levels. Advising the client to add citrus juices and bananas, which are high in potassium, would worsen the situation.

2. A patient has a new prescription for allopurinol to treat gout. What should the nurse include in the teaching?

• A. Decrease protein intake
• B. Limit salt intake
• C. Increase fluid intake
• D. Limit alcohol

Correct answer: C

Rationale: Correct answer: Increasing fluid intake is essential when taking allopurinol to prevent kidney stones and aid in uric acid excretion. This helps reduce the risk of developing complications associated with gout. Decreasing protein intake (Choice A) is not directly related to allopurinol therapy. Limiting salt intake (Choice B) and alcohol consumption (Choice D) are important for overall health but are not specific recommendations when taking allopurinol for gout.

3. A nurse manager is planning client assignments for the day. Which client should the nurse assign to the nursing assistant?

• A. A client who needs help ambulating.
• B. A client who requires complex wound care.
• C. A client who needs intravenous antibiotics.
• D. A client who is NPO and requires IV hydration.

Correct answer: A

Rationale: The correct answer is A because ambulating a client is a non-invasive task that can be safely and effectively performed by a nursing assistant. Choice B is incorrect as complex wound care requires specialized skills usually performed by licensed nurses. Choice C involves administering intravenous antibiotics, which also requires a higher level of training and assessment skills than a nursing assistant possesses. Choice D, involving a client who is NPO and requires IV hydration, may involve further assessments and monitoring that are beyond the scope of a nursing assistant.

4. Which of the following clients requiring crutches should a nurse teach about how to use a three-point gait?

• A. A client who has a right femur fracture with no weight-bearing on the affected leg
• B. A client who has bilateral leg braces due to paralysis of the lower extremities
• C. A client who has bilateral knee replacements with partial weight-bearing on both legs
• D. A client who is able to bear full weight on both lower extremities

Correct answer: A

Rationale: A three-point gait is recommended for clients who are non-weight bearing on one leg. In this case, a client with a right femur fracture requiring no weight-bearing on the affected leg would benefit from learning how to use a three-point gait. Choices B, C, and D are incorrect because they involve clients who have varying degrees of weight-bearing ability on both legs, which would not require the use of a three-point gait.

5. A nurse is providing home care for a client who is receiving tube feedings and medication through a gastrostomy tube. The family member providing the feedings reports that the client has begun to have diarrhea. For which of the following practices should the nurse intervene?

• A. Cleanse the bag every 24 hours
• B. Cleanse the bag every 48 hours
• C. Use tap water
• D. Flush the tube every 4 hours

Correct answer: A

Rationale: The correct answer is A. Cleansing the bag every 24 hours can lead to contamination, increasing the risk of infection and diarrhea. Using tap water (choice C) is not recommended for cleaning the gastrostomy tube due to the risk of introducing harmful microorganisms. Cleansing the bag every 48 hours (choice B) is not frequent enough and may also contribute to infection. Flushing the tube every 4 hours (choice D) is a standard practice to ensure patency and should not be intervened by the nurse.

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