Nursing Elites

1. Which electrolyte imbalance is commonly seen in patients receiving furosemide?

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

Correct answer: A

Rationale: The correct answer is A: Hypokalemia. Furosemide is a loop diuretic that can lead to potassium loss, resulting in hypokalemia. This electrolyte imbalance necessitates close monitoring to prevent complications such as cardiac arrhythmias. Choices B, C, and D are incorrect. Hypercalcemia is not a common side effect of furosemide. Hyponatremia is more commonly associated with other medications like thiazide diuretics. Hyperkalemia is the opposite electrolyte imbalance and is not typically seen with furosemide use.

2. A nurse is caring for a 1-day-old newborn who has jaundice and is receiving phototherapy. Which of the following actions should the nurse take?

• A. Feed the infant 30 ml (1 oz) of glucose water every 2 hours.
• B. Keep the infant's head uncovered.
• C. Ensure that the newborn wears a diaper.
• D. Apply lotion to the newborn every 4 hours.

Correct answer: C

Rationale: The correct action for the nurse to take is to ensure that the newborn wears a diaper. This is important to prevent irritation during phototherapy, as exposure to light can increase the risk of skin breakdown. Feeding the infant glucose water is unnecessary and not indicated for jaundice treatment. Keeping the infant's head uncovered allows the light to reach the skin effectively. Applying lotion to the newborn every 4 hours can interfere with the effectiveness of phototherapy and is not recommended.

3. A healthcare professional is preparing to administer an intermittent enteral feeding to a client who has a nasogastric tube. Which of the following actions should the healthcare professional take first?

• A. Check the residual volume before administering the feeding
• B. Elevate the head of the bed to 30 degrees
• C. Flush the tube with 10 mL of sterile water
• D. Verify the client's tube placement

Correct answer: D

Rationale: Verifying the client's tube placement is the priority before administering any enteral feeding. This step ensures that the tube is correctly positioned in the stomach or intestines, minimizing the risk of complications such as aspiration. Checking the residual volume, elevating the head of the bed, and flushing the tube are important steps but should occur after confirming the tube placement to ensure the feeding is delivered safely and effectively.

4. A nurse is reviewing the medical record of a client who has a history of myocardial infarction. Which of the following findings should the nurse report to the provider?

• A. Blood pressure 140/90 mm Hg
• B. Heart rate of 88/min
• C. LDL cholesterol 110 mg/dL
• D. Respiratory rate of 16/min

Correct answer: D

Rationale: In a client with a history of myocardial infarction, a respiratory rate of 16/min should be reported to the provider. Changes in respiratory rate can indicate cardiac or pulmonary issues that need further evaluation. The other vital signs provided (blood pressure, heart rate, and LDL cholesterol level) are within normal limits and do not directly relate to potential complications following a myocardial infarction.

5. What is the most critical lab value to monitor for a patient on heparin therapy?

• A. Monitor aPTT levels
• B. Monitor platelet count
• C. Monitor INR levels
• D. Monitor sodium levels

Correct answer: A

Rationale: The correct answer is to monitor aPTT levels. Activated Partial Thromboplastin Time (aPTT) is crucial for assessing the therapeutic effectiveness of heparin, as it reflects the intrinsic pathway of the coagulation cascade. Monitoring aPTT helps ensure that the patient is within the therapeutic range of heparin, minimizing the risk of bleeding complications. Platelet count (choice B) is important to assess for potential heparin-induced thrombocytopenia but is not the primary lab value to monitor during heparin therapy. INR levels (choice C) are monitored in patients on warfarin therapy, not heparin. Sodium levels (choice D) are not directly related to heparin therapy monitoring.

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