Nursing Elites

1. A nurse is reviewing the laboratory values of a client who is taking spironolactone. Which of the following values should the nurse report to the provider?

• A. Sodium 144 mEq/L
• B. Potassium 5.2 mEq/L
• C. Bicarbonate 24 mEq/L
• D. Magnesium 1.9 mEq/L

Correct answer: B

Rationale: The correct answer is B: 'Potassium 5.2 mEq/L.' When a client is taking spironolactone, which is a potassium-sparing diuretic, monitoring potassium levels is crucial. A potassium level of 5.2 mEq/L is higher than normal and can lead to cardiac dysrhythmias, so it should be reported. Choices A, C, and D are within normal ranges and would not be of immediate concern when assessing a client taking spironolactone.

2. A nurse is planning care for a client who is 1 day postoperative following a hypophysectomy for the removal of a pituitary tumor. Which of the following findings requires further assessment by the nurse?

• A. Glasgow Coma Scale score of 15
• B. Blood drainage on the initial dressing measuring 3 cm
• C. Report of dry mouth
• D. Urinary output greater than fluid intake

Correct answer: D

Rationale: The correct answer is D. Urinary output greater than fluid intake could indicate diabetes insipidus, a complication following hypophysectomy. Diabetes insipidus is characterized by excessive urination and extreme thirst due to inadequate levels of antidiuretic hormone (ADH). Options A, B, and C are all expected findings in the immediate postoperative period following a hypophysectomy. A Glasgow Coma Scale score of 15 indicates the highest level of consciousness, blood drainage on the initial dressing is a common finding after surgery, and dry mouth can be a side effect of anesthesia and surgical procedures.

3. A client is 2 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?

• A. Position the client supine with a pillow between the legs.
• B. Place an abduction pillow between the client's legs.
• C. Place a pillow under the client's knees.
• D. Position the client's legs in adduction.

Correct answer: B

Rationale: After a total hip arthroplasty, it is crucial to prevent hip dislocation. Placing an abduction pillow between the client's legs helps maintain proper alignment of the hip joint and prevents adduction, which could lead to dislocation. Therefore, choice B is the correct action. Choice A is incorrect because positioning the client supine with a pillow between the legs does not provide the necessary abduction to prevent dislocation. Choice C, placing a pillow under the client's knees, does not address the need for abduction. Choice D, positioning the client's legs in adduction, is incorrect as adduction increases the risk of hip dislocation following hip arthroplasty.

4. How should a healthcare provider manage a patient who is experiencing acute pain?

• A. Administer analgesics as prescribed
• B. Reposition the patient to alleviate pain
• C. Offer non-pharmacological interventions
• D. Administer IV fluids

Correct answer: A

Rationale: Corrected Rationale: Administering prescribed analgesics is the most effective way to manage acute pain. Analgesics help in reducing or eliminating pain quickly and efficiently. Repositioning the patient may be helpful in certain cases to relieve discomfort, but it is not the primary intervention for managing acute pain. Non-pharmacological interventions can be beneficial as adjuncts to pain management, but in cases of acute pain, administering analgesics is the priority. Administering IV fluids may be necessary for certain conditions but is not the primary intervention for managing acute pain.

5. What is the first action to take for a patient experiencing a seizure?

• A. Administer anticonvulsant medication
• B. Protect the patient's head
• C. Insert an oral airway
• D. Restrain the patient

Correct answer: B

Rationale: The first action a nurse should take for a patient experiencing a seizure is to protect the patient's head. This is crucial to prevent head injuries during the seizure. Administering anticonvulsant medication may be necessary but is not the first action. Inserting an oral airway may cause injury as the patient may bite down during a seizure. Restraint is not recommended as it can lead to further harm.

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