Nursing Elites

1. When caring for a client diagnosed with delirium, which condition is most important for the nurse to investigate?

• A. Cancer of any kind
• B. Impaired hearing
• C. Prescription drug intoxication
• D. Heart failure

Correct answer: C

Rationale: When caring for a client diagnosed with delirium, the most important condition for the nurse to investigate is prescription drug intoxication. Delirium can be caused by various factors, and prescription drug intoxication is a common reversible cause. Investigating this factor first is crucial to identify and address the underlying cause promptly. Choices A, B, and D are less likely to be directly associated with delirium compared to prescription drug intoxication. While cancer, impaired hearing, and heart failure can have their complications and effects, they are not typically the primary causes of delirium in a client.

2. 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.

3. A nurse is caring for a client with an NG tube who is experiencing nausea and decreased gastric secretions. What is the priority nursing action?

• A. Increase the suction pressure
• B. Turn the client onto their side
• C. Irrigate the NG tube with sterile water
• D. Replace the NG tube with a new one

Correct answer: D

Rationale: The correct answer is to replace the NG tube with a new one. When a client with an NG tube experiences nausea and decreased gastric secretions, it indicates a possible problem with the tube itself. Replacing the tube ensures proper functioning and can alleviate the symptoms. Increasing the suction pressure (Choice A) can worsen the client's condition. Turning the client onto their side (Choice B) may be helpful in some situations but does not address the underlying issue. Irrigating the NG tube with sterile water (Choice C) is not the priority and may not resolve the problem.

4. A client expresses doubt about the benefits of surgery. Which response by the nurse is most appropriate?

• A. Ask the client to explain why they believe the surgery won't help.
• B. Comment on the client's doubt regarding the procedure's benefits.
• C. Assure the client that everything will be fine.
• D. Acknowledge the client's uncertainty about the surgery.

Correct answer: D

Rationale: Option D is the most appropriate response as it acknowledges the client's expressed uncertainty about the surgery. By acknowledging the client's feelings, the nurse validates their concerns and opens the door for further discussion. This approach can help build trust and rapport with the client. Option A focuses more on seeking justification for the client's belief rather than addressing the underlying emotion. Option B, while acknowledging doubt, does not directly address the client's feelings. Option C, although well-intentioned, dismisses the client's concerns without exploring them further.

5. A client diagnosed with hypertension requires lifestyle changes. What change should the nurse emphasize?

• A. Increase intake of high-fat foods
• B. Reduce sodium intake
• C. Reduce intake of dairy products
• D. Increase intake of high-protein foods

Correct answer: B

Rationale: Reducing sodium intake is crucial for managing hypertension as excess sodium can lead to increased blood pressure. High-fat foods (Choice A) are not recommended as they can contribute to heart issues. While dairy products (Choice C) should be consumed in moderation, they are not specifically targeted in hypertension management. High-protein foods (Choice D) are not the priority; rather, reducing sodium intake takes precedence due to its direct impact on blood pressure levels.

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