Nursing Elites

1. Which instruction should the nurse provide to an elderly client who is taking an ACE inhibitor and a calcium channel blocker?

• A. Wear long-sleeved clothing when outdoors
• B. Report the onset of sore throat
• C. Eat plenty of potassium-rich food
• D. Change the position slowly

Correct answer: D

Rationale: The correct instruction for an elderly client taking both an ACE inhibitor and a calcium channel blocker is to change positions slowly. Both medications can lead to orthostatic hypotension, a sudden drop in blood pressure when changing positions, which can increase the risk of falls. Instructing the client to change positions slowly helps prevent falls. Wearing long-sleeved clothing when outdoors does not directly relate to the medication combination. Reporting the onset of a sore throat is important for monitoring potential side effects but is not specific to these medications. While potassium levels should be monitored with ACE inhibitors, eating plenty of potassium-rich foods without guidance can lead to hyperkalemia, a potential side effect of ACE inhibitors.

2. A nurse is caring for a client with a new colostomy. Which instruction should the nurse include in the client's teaching plan?

• A. Change the ostomy appliance daily
• B. Empty the ostomy pouch when it is one-third full
• C. Rinse the ostomy pouch with warm water
• D. Apply a skin barrier to the peristomal skin

Correct answer: B

Rationale: The correct instruction the nurse should include in the client's teaching plan is to empty the ostomy pouch when it is one-third full. This practice helps prevent leakage and skin irritation by maintaining an appropriate pouching system. Changing the ostomy appliance daily (Choice A) is not necessary unless leakage or other issues occur. Rinsing the ostomy pouch with warm water (Choice C) is not a recommended practice as it may cause damage to the pouch. Applying a skin barrier to the peristomal skin (Choice D) is important but not the most crucial instruction in this scenario.

3. The nurse is planning care for a client who is receiving phenytoin (Dilantin) for seizure control. Which intervention is most important to include in this client’s plan of care?

• A. Monitor serum calcium levels
• B. Obtain a baseline electrocardiogram
• C. Implement seizure precautions
• D. Encourage a low-protein diet

Correct answer: C

Rationale: The correct answer is to implement seizure precautions. Phenytoin is an antiepileptic medication used for seizure control. Seizure precautions are crucial for clients taking this medication to ensure their safety during a seizure episode. Monitoring serum calcium levels (Choice A) is not directly related to phenytoin therapy. Obtaining a baseline electrocardiogram (Choice B) is important for some medications but not the priority for a client on phenytoin. Encouraging a low-protein diet (Choice D) is not specifically indicated for clients on phenytoin and is not the most important intervention.

4. The nurse is administering total parenteral nutrition (TPN) via a central line at 75 ml/hour to a client who had a bowel resection 4 days ago. Which laboratory finding requires the most immediate intervention by the nurse?

• A. Blood glucose of 140 mg/dL
• B. White blood cell count of 8000/mm³
• C. Serum potassium of 3.8 mEq/L
• D. Serum calcium of 7.8 mg/dL

Correct answer: D

Rationale: The correct answer is D. A serum calcium level of 7.8 mg/dL requires immediate intervention due to the risk of hypocalcemia. Hypocalcemia can lead to serious complications such as tetany, seizures, and cardiac arrhythmias. The other laboratory findings are within normal limits or slightly elevated, which do not pose an immediate threat to the client's health in this scenario.

5. A client with diabetes mellitus reports feeling shaky and has a blood glucose level of 60 mg/dl. What action should the nurse take?

• A. Administer 15 grams of carbohydrate
• B. Administer a glucagon injection
• C. Provide a snack with protein
• D. Encourage the client to rest

Correct answer: A

Rationale: In the scenario described, the client is experiencing hypoglycemia with a blood glucose level of 60 mg/dl. The appropriate action for the nurse to take is to administer 15 grams of carbohydrate. Carbohydrate intake helps to rapidly raise blood sugar levels in cases of hypoglycemia. Administering a glucagon injection (Choice B) is not the initial treatment for mild hypoglycemia; it is typically used for severe hypoglycemia when the client is unable to consume oral carbohydrates. Providing a snack with protein (Choice C) is not the first-line intervention for hypoglycemia; immediate carbohydrate intake is necessary to raise blood sugar levels quickly. Encouraging the client to rest (Choice D) may be appropriate after administering the carbohydrate, but the priority is to address the low blood glucose levels by administering carbohydrates first.

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