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. The nurse reports that a client is at risk for a brain attack (stroke) based on which assessment finding?

• A. Nuchal rigidity
• B. Carotid bruit
• C. Jugular vein distention
• D. Palpable cervical lymph node

Correct answer: B

Rationale: The correct answer is B: Carotid bruit. A carotid bruit is a significant risk factor for stroke as it indicates turbulent blood flow due to narrowing of the carotid artery. Nuchal rigidity is associated with meningitis, jugular vein distention can be a sign of heart failure, and palpable cervical lymph nodes may indicate infection, but they are not directly linked to stroke risk.

3. Which individual has the highest risk for developing skin cancer?

• A. A 16-year-old dark-skinned female who tans in tanning beds once a week.
• B. A 65-year-old fair-skinned male who is a construction worker
• C. A 25-year-old dark-skinned male whose mother had skin cancer.
• D. A 70-year-old fair-skinned female who works as a secretary.

Correct answer: B

Rationale: The correct answer is B, a 65-year-old fair-skinned male who is a construction worker. Fair-skinned individuals are at higher risk of developing skin cancer due to prolonged sun exposure. Construction workers are often exposed to the sun for long periods, further increasing the risk. Choices A, C, and D are less likely to develop skin cancer compared to choice B due to factors such as age, frequency of tanning bed use, and occupation.

4. The nurse is providing discharge teaching for a client with heart failure. Which instruction should be included to prevent fluid overload?

• A. Weigh yourself daily and report a gain of 2 pounds in 24 hours
• B. Increase fluid intake to stay hydrated
• C. Consume a high-sodium diet to retain fluids
• D. Engage in vigorous exercise daily

Correct answer: A

Rationale: The correct answer is A: 'Weigh yourself daily and report a gain of 2 pounds in 24 hours.' Daily weight monitoring is crucial for detecting fluid retention early in clients with heart failure. Reporting a gain of 2 pounds in 24 hours can indicate fluid overload, prompting timely intervention. Choice B is incorrect because increasing fluid intake can exacerbate fluid overload in clients with heart failure. Choice C is incorrect as a high-sodium diet can worsen fluid retention. Choice D is incorrect as vigorous exercise can strain the heart and worsen heart failure symptoms.

5. What are early signs of varicella disease?

• A. High fever over 101°F (38.3°C)
• B. General malaise
• C. Increased appetite
• D. Crusty sores

Correct answer: B

Rationale: The correct early sign of varicella disease is general malaise. During the prodromal period, patients may experience low-grade fever, malaise, and anorexia. Increased appetite and crusty sores are not typically early signs of varicella. The appearance of lesions occurs later in the course of the disease.

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