Nursing Elites

1. Which client requires careful nursing assessment for signs and symptoms of hypomagnesaemia?

• A. A young adult client with intractable vomiting due to food poisoning
• B. A client who developed hyperparathyroidism in late adolescence
• C. A middle-aged male client in renal failure following an unsuccessful kidney transplant
• D. A female client who excessively consumes simple carbohydrates

Correct answer: C

Rationale: The correct answer is C. Clients in renal failure are at high risk for hypomagnesemia due to their impaired kidney function. Renal failure can lead to decreased excretion of magnesium, resulting in its buildup in the body and potential hypomagnesemia. This client requires careful nursing assessment for signs and symptoms of hypomagnesemia to prevent complications. Choices A, B, and D are not as directly associated with renal failure and its impact on magnesium levels. Intractable vomiting, hyperparathyroidism, and excessive consumption of simple carbohydrates may have other health implications but are not as strongly linked to hypomagnesemia as renal failure.

2. A client who is 32-weeks pregnant is diagnosed with partial placenta previa. Which instruction should the nurse include in this client’s teaching plan?

• A. Wear a tight abdominal binder at all times
• B. Take a daily laxative to prevent constipation
• C. Refrain from sexual intercourse until your next appointment
• D. Restrict fluids to less than 1000 ml per day

Correct answer: C

Rationale: Refraining from sexual intercourse helps prevent complications with partial placenta previa.

3. Oxygen at liters/min per nasal cannula PRN difficult breathing is prescribed for a client with pneumonia. Which nursing intervention is effective in preventing oxygen toxicity?

• A. Avoiding the administration of high levels of oxygen for extended periods.
• B. Administering a sedative at bedtime to slow the client's respiratory rate.
• C. Removing the nasal cannula during the night to prevent oxygen buildup.
• D. Running oxygen through a hydration source prior to administration.

Correct answer: A

Rationale: The correct answer is A: Avoiding the administration of high levels of oxygen for extended periods. Oxygen toxicity can occur when high levels of oxygen are given for a prolonged period. It is important to monitor and adjust the oxygen levels as needed to prevent toxicity. Choice B is incorrect because administering a sedative to slow the respiratory rate does not directly prevent oxygen toxicity. Choice C is incorrect as removing the nasal cannula during the night can compromise the client's oxygenation. Choice D is incorrect as running oxygen through a hydration source does not prevent oxygen toxicity; instead, it may introduce risks associated with the hydration source.

4. A nurse is planning care for a client in the late stage of amyotrophic lateral sclerosis (ALS). Which nursing diagnosis has the highest priority?

• A. Impaired physical mobility
• B. Ineffective breathing pattern
• C. Impaired skin integrity
• D. Risk for infection

Correct answer: B

Rationale: Ineffective breathing pattern is the highest priority for a client in the late stage of ALS due to the significant risk of respiratory complications. As ALS progresses, the client may experience respiratory muscle weakness, leading to ineffective breathing patterns and potential respiratory failure. Addressing breathing difficulties promptly is crucial to ensure adequate oxygenation and prevent further complications. While impaired physical mobility, impaired skin integrity, and risk for infection are also important concerns in ALS care, they are secondary to addressing the client's breathing difficulties, which take precedence to maintain physiological stability and prevent life-threatening consequences.

5. The nurse enters the room of a client with a nasogastric tube who is receiving continuous feeding. The nurse observes that the client is coughing and that the infusion pump is alarming. What action should the nurse take first?

• A. Auscultate the client's breath sounds
• B. Turn the client to the side
• C. Stop the feeding infusion
• D. Notify the healthcare provider

Correct answer: C

Rationale: The correct action for the nurse to take first in this situation is to stop the feeding infusion. Coughing in a client with a nasogastric tube can indicate aspiration, which can be a serious complication. By stopping the feeding infusion immediately, the nurse can prevent further aspiration and related complications. Auscultating breath sounds or turning the client to the side may be necessary actions but addressing the feeding infusion is the priority. Notifying the healthcare provider can be done after the immediate issue of potential aspiration is managed.

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