Nursing Elites

1. A nurse is reviewing the medical record of a client who is taking furosemide. Which of the following findings should the nurse report to the provider?

• A. Potassium level of 3.8 mEq/L
• B. Sodium level of 135 mEq/L
• C. Magnesium level of 1.6 mEq/L
• D. Calcium level of 8.5 mg/dL

Correct answer: C

Rationale: The correct answer is C. A magnesium level of 1.6 mEq/L is within the normal range, but monitoring potassium levels is crucial for clients taking furosemide. Furosemide can cause hypokalemia (low potassium levels), which can lead to adverse effects such as cardiac dysrhythmias. Sodium and calcium levels are not typically affected by furosemide, so they are not the priority findings to report to the provider in this case.

2. A client who experienced an acute myocardial infarction expresses concern about fatigue. What is the best strategy to promote self-care?

• A. Ask family members to assist with all self-care tasks
• B. Encourage the client to gradually resume self-care tasks with frequent rest periods
• C. Instruct the client to remain in bed until fully rested
• D. Assign assistive personnel to complete self-care tasks for the client

Correct answer: B

Rationale: Encouraging the client to gradually resume self-care tasks with frequent rest periods is the best strategy to promote self-care for a client who experienced an acute myocardial infarction and is experiencing fatigue. This approach helps the client regain independence while managing fatigue. Asking family members to assist with all self-care tasks (Choice A) may hinder the client's independence. Instructing the client to remain in bed until fully rested (Choice C) may lead to deconditioning and dependency. Assigning assistive personnel to complete self-care tasks for the client (Choice D) does not empower the client to regain independence or actively participate in self-care.

3. A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk of injury for this client?

• A. Use a bed exit alarm system
• B. Raise all four side rails while the client is in bed
• C. Apply one soft wrist restraint
• D. Dim the lights in the client's room

Correct answer: A

Rationale: Using a bed exit alarm system is crucial in minimizing the risk of injury for a client with dementia. This intervention helps alert staff when the client is attempting to leave the bed, reducing the chances of falls. Raising all four side rails while the client is in bed (Choice B) can lead to restraint-related issues and is not recommended unless necessary for safety reasons. Applying a soft wrist restraint (Choice C) is generally not the first choice in managing clients with dementia due to the risk of complications and loss of mobility. Dimming the lights in the client's room (Choice D) may not directly address the risk of injury associated with dementia and may even increase the risk of falls due to poor visibility.

4. A healthcare provider is checking a newborn's vital signs. Which of the following methods of temperature measurement should the healthcare provider use?

• A. Rectal
• B. Axillary
• C. Oral
• D. Tympanic

Correct answer: B

Rationale: The axillary method is the most appropriate for newborns because it is non-invasive and safe. Rectal temperature measurement can be uncomfortable and poses a risk of injury, especially in newborns. Oral temperature measurement is not recommended for newborns due to their inability to cooperate and potential inaccuracies. Tympanic temperature measurement may not be as accurate in newborns compared to older children or adults.

5. A nurse is reviewing the plan of care for a client who is undergoing total parenteral nutrition (TPN). Which of the following interventions should the nurse include?

• A. Monitor the client's electrolyte levels daily
• B. Weigh the client daily
• C. Monitor the client's blood glucose levels every 6 hours
• D. Change the TPN tubing every 24 hours

Correct answer: D

Rationale: The correct intervention for the nurse to include in the plan of care for a client undergoing total parenteral nutrition (TPN) is to change the TPN tubing every 24 hours. Changing the tubing at regular intervals helps reduce the risk of infection associated with central venous catheters. Monitoring electrolyte levels daily (Choice A) is important but not specific to TPN. Weighing the client daily (Choice B) is important for monitoring fluid status but not directly related to TPN. Monitoring blood glucose levels every 6 hours (Choice C) is essential for clients receiving TPN, but changing the tubing is a more critical intervention to prevent infections.

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