Nursing Elites

1. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse report to the provider?

• A. Blood glucose level of 150 mg/dL
• B. Serum sodium level of 138 mEq/L
• C. Serum potassium level of 3.0 mEq/L
• D. Serum albumin level of 3.8 g/dL

Correct answer: C

Rationale: The correct answer is C. A serum potassium level of 3.0 mEq/L is below the normal range and indicates hypokalemia, which should be reported to the provider. Hypokalemia can lead to serious complications such as cardiac arrhythmias. Choices A, B, and D are within normal ranges and do not require immediate reporting. A blood glucose level of 150 mg/dL is slightly elevated but not critically high. A serum sodium level of 138 mEq/L is within the normal range. A serum albumin level of 3.8 g/dL is also within the normal range.

2. What is the appropriate nursing action for a patient experiencing an acute allergic reaction?

• A. Administer antihistamines
• B. Administer corticosteroids
• C. Administer oxygen
• D. Administer bronchodilators

Correct answer: A

Rationale: The appropriate nursing action for a patient experiencing an acute allergic reaction is to administer antihistamines. Antihistamines work by blocking the action of histamine, a chemical released during an allergic reaction, and can help relieve symptoms such as itching, swelling, and hives. Corticosteroids are used for severe allergic reactions not responding to antihistamines, as they have anti-inflammatory properties. Oxygen is administered in cases of respiratory distress, while bronchodilators are used for bronchospasms. However, the first-line intervention for an acute allergic reaction is antihistamines.

3. A nurse in a mental health facility receives a change of shift report on four clients. Which of the following clients should the nurse plan to assess first?

• A. Client placed in restraints due to aggressive behavior
• B. A new client with a history of 4.5 kg weight loss in the past two months
• C. Client receiving PRN dose of haloperidol 2 hours ago for anxiety
• D. Client receiving first ECT treatment today

Correct answer: A

Rationale: The nurse should plan to assess the client placed in restraints due to aggressive behavior first. Clients in restraints require immediate attention and frequent monitoring for safety. While weight loss, medication administration, and ECT treatment are important, the client in restraints is in a critical situation that requires immediate assessment and intervention.

4. A nurse is admitting a client who has schizophrenia and experiences auditory hallucinations. The client states, 'It's hard not to listen to the voices.' Which of the following questions should the nurse ask?

• A. Do you understand that the voices are not real?
• B. Why do you think the voices are talking to you?
• C. Have you tried going to a private place when this occurs?
• D. What helps you ignore what you are hearing?

Correct answer: D

Rationale: The correct answer is 'D: What helps you ignore what you are hearing?' Asking the client about coping mechanisms is essential in assisting them to manage auditory hallucinations. Choice A is incorrect as questioning the reality of the voices may not be helpful. Choice B delves into the cause of the hallucinations rather than coping strategies. Choice C focuses on isolation rather than addressing the client's coping mechanisms.

5. When administering an incorrect dose of medication, which facts 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 nurse should document the time the medication was given in the client's medical record when administering an incorrect dose. This information is crucial for tracking the sequence of events leading to the error. Choice B, the client's response to the medication, is important for monitoring the client's condition post-administration but may not be directly linked to the incident report. Choice C, documenting the dose that was administered, is relevant but does not provide insights into the timing of events. Choice D, detailing the reason for the error, should be included in the incident report but may not need to be documented in the client's medical record.

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