Nursing Elites

1. A nurse is reviewing the medical record of a client who has a new prescription for potassium chloride. Which of the following findings should the nurse report to the provider?

• A. Blood pressure 110/70 mm Hg
• B. Heart rate 88/min
• C. Serum potassium 3.2 mEq/L
• D. Sodium 136 mEq/L

Correct answer: C

Rationale: The correct answer is C. A serum potassium level of 3.2 mEq/L is below the normal range, indicating hypokalemia. Before administering potassium chloride, which is used to treat low potassium levels, the nurse should report this finding to the provider for further evaluation and potential adjustment of the treatment plan. Choices A, B, and D are within normal ranges and do not directly relate to the need for potassium chloride administration.

2. A nurse is planning care for a client who has pneumonia. Which of the following actions should the nurse take to promote airway clearance?

• A. Perform chest physiotherapy every 4 hours.
• B. Suction the client every 2 hours.
• C. Encourage the client to increase fluid intake.
• D. Administer oxygen via nasal cannula.

Correct answer: C

Rationale: Encouraging the client to increase fluid intake is essential in promoting airway clearance for a client with pneumonia. Increased fluid intake helps thin secretions, making it easier for the client to clear their airways. Chest physiotherapy (Choice A) is more focused on mobilizing secretions and may not be suitable for all clients with pneumonia. Suctioning (Choice B) is indicated for clients who have excessive secretions that they cannot manage effectively themselves. Administering oxygen via nasal cannula (Choice D) is important for clients with pneumonia to maintain adequate oxygenation, but it does not directly promote airway clearance.

3. A client with schizophrenia is beginning therapy with clozapine. Which statement indicates a need for further teaching?

• A. I will need to have my blood work checked regularly while taking clozapine.
• B. I understand that clozapine may cause me to gain weight.
• C. I should report any signs of a fever while taking clozapine.
• D. I should discontinue clozapine once my symptoms improve.

Correct answer: D

Rationale: The correct answer is D because clients should continue taking clozapine even if their symptoms improve. Abruptly discontinuing the medication can lead to relapse. Choices A, B, and C are all correct statements regarding clozapine therapy. Regular blood work monitoring is necessary due to potential side effects, weight gain is a common side effect of clozapine, and reporting signs of fever is important as it can indicate a serious side effect of clozapine.

4. A group of newly licensed nurses is being taught about client advocacy by a nurse. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching?

• A. I will intervene if there is a conflict between a client and their provider.
• B. I should not advocate for a client unless they are able to ask me themselves.
• C. I will inform a client that their family should help make their health care decisions.
• D. I believe the best health care decision is for the provider to decide.

Correct answer: B

Rationale: The correct answer is B because advocating for a client should not be dependent on the client's ability to ask for it personally. Advocacy is crucial to ensure clients' rights are upheld, especially when they are unable to express their wishes. Choice A is incorrect as intervening in a conflict may not always be advocating for the client's best interests. Choice C is incorrect because the family should not make health care decisions for the client without their input. Choice D is incorrect as it disregards the importance of client autonomy and involvement in decision-making.

5. A nurse is assessing a client who has hypothyroidism. Which of the following findings should the nurse expect?

• A. Bradycardia
• B. Weight gain
• C. Hypertension
• D. Decreased deep tendon reflexes

Correct answer: D

Rationale: Corrected Rationale: Decreased deep tendon reflexes are a common finding in clients with hypothyroidism due to slowed metabolic processes. The other choices, such as bradycardia (slow heart rate), weight gain, and hypertension (high blood pressure) are not typically associated with hypothyroidism. Bradycardia can occur due to the decreased metabolic rate, but it is not a consistent finding. Weight gain is common but not universal, and hypertension is more commonly associated with hyperthyroidism.

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