Nursing Elites

1. A nurse is reviewing the medical record of a client who has a history of angina and is scheduled for surgery. Which of the following findings should the nurse report to the provider?

• A. Serum potassium level of 4.2 mEq/L
• B. Blood pressure of 138/84 mm Hg
• C. Platelet count of 150,000/mm³
• D. INR of 2.0

Correct answer: D

Rationale: The correct answer is D. An INR of 2.0 is within the therapeutic range for clients receiving warfarin. It is crucial to report this finding to the provider before surgery to ensure appropriate management and potential adjustments to prevent excessive bleeding risks. Choices A, B, and C are within normal limits and do not directly impact the client's surgery preparation or risk for bleeding, so they do not require immediate reporting.

2. A nurse is preparing to administer a controlled substance. Which of the following actions should the nurse take?

• A. Witness the waste of the controlled substance by another nurse
• B. Dispose of the controlled substance by yourself
• C. Leave the controlled substance in the client's room for later use
• D. Document the administration and sign off at the end of the shift

Correct answer: A

Rationale: The correct action for the nurse preparing to administer a controlled substance is to witness the waste of the controlled substance by another nurse. This practice is crucial to prevent misuse and ensure accurate documentation. Choice B is incorrect because disposing of the controlled substance by oneself without proper witnessing is not in accordance with safety protocols. Choice C is incorrect as leaving a controlled substance unattended in a client's room poses risks of diversion or unauthorized access. Choice D is incorrect because documenting the administration and signing off at the end of the shift is important but does not specifically address the issue of witnessing the waste of a controlled substance, which is a critical step in ensuring proper handling and accountability.

3. A client is postoperative following a total knee arthroplasty. Which of the following instructions should the nurse include in the discharge teaching?

• A. Cross your legs when sitting to prevent discomfort.
• B. Perform range-of-motion exercises every 4 hours.
• C. Wear compression stockings daily.
• D. Apply heat to the incision site daily.

Correct answer: C

Rationale: The correct answer is C: 'Wear compression stockings daily.' Wearing compression stockings is essential after knee surgery to prevent venous stasis and reduce the risk of blood clots. Choice A is incorrect as crossing legs when sitting can increase the risk of blood clots. Choice B is incorrect because performing range-of-motion exercises every 4 hours may not be suitable for all clients post total knee arthroplasty. Choice D is incorrect as applying heat to the incision site can increase the risk of infection.

4. A nurse is caring for a client who has a prescription for spironolactone. Which of the following laboratory values should the nurse monitor?

• A. Sodium 140 mEq/L
• B. Calcium 9.5 mg/dL
• C. Potassium 5.2 mEq/L
• D. Magnesium 2.0 mEq/L

Correct answer: C

Rationale: The correct answer is C: Potassium 5.2 mEq/L. A potassium level of 5.2 mEq/L is elevated and should be monitored in clients taking spironolactone, which is a potassium-sparing medication. Monitoring potassium levels is crucial as spironolactone can cause hyperkalemia. Choices A, B, and D are incorrect because sodium, calcium, and magnesium levels are not typically affected by spironolactone. Therefore, the nurse should primarily focus on monitoring the potassium levels in this scenario.

5. A healthcare provider is assessing a child who is being treated for bacterial pneumonia. The provider notes an increase in the child's glucose level. The provider should identify this finding as an adverse effect of which of the following medications?

• A. Methylprednisolone.
• B. Ondansetron.
• C. Guaifenesin.
• D. Amoxicillin.

Correct answer: A

Rationale: Correct. Methylprednisolone, a corticosteroid, can lead to increased glucose levels as an adverse effect. Ondansetron is an antiemetic and does not typically cause elevated glucose levels. Guaifenesin is an expectorant and is not associated with raising glucose levels. Amoxicillin is an antibiotic and does not affect glucose levels.

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