Nursing Elites

1. Laboratory findings indicate that a client’s serum potassium level is 2.5 mEq/L. What action should the nurse take?

• A. Administer potassium supplements orally.
• B. Increase the client's dietary potassium intake.
• C. Inform the healthcare provider of the need for potassium replacement.
• D. Monitor the client's ECG continuously.

Correct answer: C

Rationale: A serum potassium level of 2.5 mEq/L is critically low, indicating severe hypokalemia. In this situation, it is essential for the nurse to inform the healthcare provider promptly about the need for potassium replacement. Administering potassium supplements orally or increasing dietary potassium intake is not appropriate in cases of critically low potassium levels as immediate and precise replacement is necessary. Monitoring the client's ECG continuously is important in severe cases of hypokalemia, but the priority action should be to inform the healthcare provider for further management and treatment.

2. What is the most common clinical manifestation of coarctation of the aorta?

• A. Clubbing of the digits
• B. Upper extremity hypertension
• C. Pedal edema and portal congestion
• D. Loud systolic ejection murmur

Correct answer: B

Rationale: The correct answer is B: Upper extremity hypertension. Coarctation of the aorta leads to increased blood pressure in the upper extremities. The pressure in the arms is typically 20 mm Hg higher than in the legs. Choice A, clubbing of the digits, is not a common clinical manifestation of coarctation of the aorta. Choice C, pedal edema, and portal congestion are more suggestive of conditions like heart failure rather than coarctation of the aorta. Choice D, loud systolic ejection murmur, can be heard in conditions like aortic stenosis, but it is not the most common clinical manifestation of coarctation of the aorta.

3. What is the most effective therapy for maintaining remission of acute lymphoblastic leukemia in a child?

• A. Surgery to remove enlarged lymph nodes
• B. Long-term chemotherapy
• C. Nutritional supplements to enhance blood cell production
• D. Blood transfusions to replace ineffective red cells

Correct answer: B

Rationale: The correct answer is B: Long-term chemotherapy. In the case of acute lymphoblastic leukemia, the most effective approach for maintaining remission is long-term chemotherapy, particularly with methotrexate, a chemotherapeutic agent. Surgery to remove enlarged lymph nodes (choice A) is not the primary treatment for leukemia. Nutritional supplements (choice C) may be beneficial for overall health but are not the mainstay of leukemia treatment. Blood transfusions (choice D) are used to manage anemia in leukemia but do not address the underlying disease process.

4. Which nursing problem has the highest priority when planning care for a client with Meniere’s disease?

• A. Potential for injury related to vertigo.
• B. Alteration in comfort due to ear pain.
• C. Impaired skin integrity due to immobility.
• D. Anxiety due to fear of falling.

Correct answer: A

Rationale: The correct answer is A. When caring for a client with Meniere’s disease, the highest priority nursing problem is the potential for injury related to vertigo. Meniere’s disease is characterized by symptoms like vertigo, which can increase the risk of falls and injuries. Ensuring the client's safety and preventing falls take precedence over other concerns. Choices B, C, and D are not the highest priority because they do not directly address the immediate risk of harm associated with vertigo and falls.

5. Following surgical repair of the bladder, a female client is being discharged from the hospital to home with an indwelling urinary catheter. Which instruction is most important for the nurse to provide to this client?

• A. Avoid coiling the tubing and keep it free of kinks.
• B. Cleanse the perineal area with soap and water twice daily.
• C. Keep the drainage bag lower than the level of the bladder.
• D. Drink 1,000 ml of fluids daily to irrigate the catheter.

Correct answer: C

Rationale: The most crucial instruction for a client with an indwelling urinary catheter post-bladder surgery is to keep the drainage bag positioned lower than the level of the bladder. This positioning prevents backflow of urine into the bladder, reducing the risk of infection. Choice A, avoiding coiling the tubing and keeping it free of kinks, is important to maintain proper flow but not as critical as ensuring the drainage bag is lower than the bladder. Choice B, cleansing the perineal area, is essential for overall hygiene but not directly related to catheter care instructions. Choice D, drinking fluids to irrigate the catheter, is not recommended as it may increase the risk of infection and should be guided by healthcare providers based on specific needs.

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