Nursing Elites

1. Which electrolyte imbalance is a common concern in patients receiving loop diuretics?

• A. Hyperkalemia
• B. Hyponatremia
• C. Hypokalemia
• D. Hypercalcemia

Correct answer: C

Rationale: The correct answer is Hypokalemia (Choice C). Loop diuretics can lead to potassium loss in the urine, resulting in hypokalemia. This electrolyte imbalance is a common concern with loop diuretic therapy and necessitates regular monitoring. Hyperkalemia (Choice A) is not typically associated with loop diuretics but with conditions like renal failure. Hyponatremia (Choice B) is more common with thiazide diuretics. Hypercalcemia (Choice D) is not a typical concern with loop diuretic use.

2. A nurse is preparing to administer an intermittent enteral feeding to a client who has an NG tube. Which of the following actions should the nurse take?

• A. Heat the feeding to 105°F (40.6°C).
• B. Elevate the head of the bed to 45 degrees.
• C. Flush the tube with 0.9% sodium chloride.
• D. Verify the pH of the gastric aspirate.

Correct answer: D

Rationale: Verifying the pH of the gastric aspirate is the correct action to take before administering an intermittent enteral feeding through an NG tube. This step ensures proper tube placement in the stomach, as the gastric aspirate should have an acidic pH (usually below 5). Heating the feeding solution, elevating the head of the bed, or flushing the tube with saline are not directly related to verifying tube placement and are not the immediate actions needed before administering the feeding.

3. A nurse is caring for a client who is scheduled for a colonoscopy. Which of the following findings should the nurse report to the provider?

• A. Client reports taking ibuprofen daily
• B. Client has a history of asthma
• C. Client reports drinking one glass of wine daily
• D. Client has a history of diverticulitis

Correct answer: A

Rationale: The correct answer is A. Ibuprofen is an NSAID that can increase the risk of bleeding during a colonoscopy due to its effects on platelet function. It is important to report this finding to the provider to consider alternative pain management options. Choices B, C, and D are not the most pertinent to report for a colonoscopy. Asthma and a history of diverticulitis are relevant medical history but do not directly impact the colonoscopy procedure. Drinking one glass of wine daily is not a concern specifically related to the colonoscopy procedure.

4. A nurse is admitting a client who is in labor and at 38 wks of gestation to the maternal newborn unit. The client has a history of herpes simplex virus 2. Which of the following questions is most appropriate for the nurse to ask the client?

• A. Have your membranes ruptured?
• B. How far apart are your contractions?
• C. Do you have any active lesions?
• D. Are you positive for beta strep?

Correct answer: C

Rationale: The most appropriate question for the nurse to ask the client in this situation is whether they have any active lesions due to the history of herpes simplex virus. This is crucial to assess the risk of transmission to the newborn during labor. Option A is not the priority in this case as the focus is on the client's history of herpes simplex virus. Option B is important but does not directly relate to the risk of herpes simplex virus transmission. Option D is unrelated to the client's condition and the current situation.

5. A nurse is caring for a client who is at risk for developing deep vein thrombosis (DVT). Which of the following actions should the nurse implement?

• A. Massage the client's legs every 2 hours.
• B. Encourage the client to remain on bed rest.
• C. Apply sequential compression devices to the client's legs.
• D. Administer anticoagulants as prescribed.

Correct answer: C

Rationale: The correct action the nurse should implement is to apply sequential compression devices to the client's legs. This intervention helps prevent venous stasis and reduce the risk of deep vein thrombosis (DVT). Massaging the client's legs may dislodge a clot and is contraindicated in this situation (choice A). Encouraging bed rest may increase the risk of DVT due to prolonged immobility (choice B). While administering anticoagulants is a common treatment for DVT, in this case, the question is about preventive measures, and using sequential compression devices is a non-pharmacological approach.

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