Nursing Elites

1. The patient has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan?

• A. Maintain the patient on bed rest.
• B. Auscultate lung sounds every 4 hours.
• C. Monitor for Trousseau's and Chvostek's signs.
• D. Encourage fluid intake up to 4000 mL every day.

Correct answer: D

Rationale: The correct action for the nurse to include on the care plan for a patient with a calcium level of 12.1 mg/dL is to encourage fluid intake up to 4000 mL every day. This is essential to decrease the risk for renal calculi associated with hypercalcemia. While bed rest is not necessary, ambulation is encouraged to help decrease the loss of calcium from the bone. Monitoring for Trousseau's and Chvostek's signs is more relevant when hypocalcemia is suspected. Auscultating lung sounds every shift is a routine assessment, not required every 4 hours unless there is a specific respiratory concern.

2. The healthcare professional is caring for a client with a chest tube following a thoracotomy. Which assessment finding requires immediate intervention?

• A. Continuous bubbling in the water seal chamber.
• B. Serosanguineous drainage in the collection chamber.
• C. Intermittent bubbling in the suction control chamber.
• D. Chest tube secured to the client's chest wall.

Correct answer: A

Rationale: Continuous bubbling in the water seal chamber indicates an air leak, which requires immediate intervention to prevent complications such as pneumothorax. An air leak can lead to ineffective lung expansion, respiratory distress, and compromised gas exchange. Therefore, prompt action is necessary to maintain the integrity of the closed drainage system and prevent further complications. Choices B, C, and D are incorrect because serosanguineous drainage is an expected finding post-thoracotomy, intermittent bubbling in the suction control chamber is normal, and having the chest tube secured to the client's chest wall is essential for stability and proper functioning.

3. A client with a history of diabetes mellitus is admitted with a foot ulcer. The nurse should recognize that which intervention is most critical in promoting healing of the foot ulcer?

• A. Strict control of blood glucose levels.
• B. Regular dressing changes with sterile technique.
• C. Application of antibiotic ointment.
• D. Hydrotherapy treatment daily.

Correct answer: A

Rationale: In diabetic clients with foot ulcers, strict control of blood glucose levels is essential for promoting wound healing. High blood glucose levels can impair circulation and compromise the body's ability to fight infection, delaying the healing process. By maintaining optimal blood glucose levels, the client's overall health and wound healing potential are improved.

4. A client with type 1 diabetes mellitus is admitted with hyperglycemia. Which laboratory result requires the most immediate intervention?

• A. Serum glucose of 350 mg/dL.
• B. Serum potassium of 2.8 mEq/L.
• C. Serum sodium of 136 mEq/L.
• D. Serum bicarbonate of 20 mEq/L.

Correct answer: B

Rationale: A serum potassium level of 2.8 mEq/L is critically low and can cause cardiac arrhythmias, requiring immediate intervention. Hypokalemia is a life-threatening condition that needs prompt correction to prevent serious complications. High serum glucose levels (choice A) are a concern in diabetes but do not pose an immediate life-threatening risk compared to severe hypokalemia. Serum sodium (choice C) and serum bicarbonate levels (choice D) are within normal ranges and do not require immediate intervention.

5. A client with heart failure is prescribed digoxin (Lanoxin). Which instruction should the nurse include in the client's teaching plan?

• A. Take your pulse before each dose and hold the medication if your pulse is below 60 beats per minute.
• B. Increase your intake of foods high in potassium.
• C. Take the medication with a high-fiber meal to enhance absorption.
• D. Skip a dose if you feel dizzy or lightheaded.

Correct answer: A

Rationale: The correct instruction for a client prescribed digoxin is to take their pulse before each dose and hold the medication if the pulse is below 60 beats per minute. This is crucial to prevent digoxin toxicity, as digoxin can cause adverse effects when the pulse rate is too low. Monitoring the pulse regularly ensures safety and appropriate management of the medication.

Similar Questions