Nursing Elites

1. Which nursing action is best when managing a client with severe anxiety?

• A. Maintain a calm manner
• B. Help the client identify thoughts prior to the anxiety
• C. Administer anti-anxiety medication
• D. Initiate seclusion if anxiety escalates

Correct answer: A

Rationale: The correct answer is to maintain a calm manner. When managing a client with severe anxiety, the nurse's calm presence can help the client feel more secure and reduce their anxiety levels. It is essential to create a safe and supportive environment. Helping the client identify thoughts prior to anxiety (choice B) may be beneficial in cognitive-behavioral interventions but may not be the initial best action for severe anxiety. Administering anti-anxiety medication (choice C) should be done by a healthcare provider's order and is not the first-line intervention for managing severe anxiety. Initiating seclusion (choice D) should only be considered as a last resort if the client is at risk of harm to themselves or others, as it can further escalate anxiety and should not be the initial action.

2. What are the key signs of hyperkalemia and how should it be treated?

• A. Elevated potassium levels, muscle weakness; administer calcium gluconate
• B. Decreased potassium levels, confusion; administer potassium chloride
• C. Elevated sodium levels, bradycardia; administer sodium bicarbonate
• D. Low sodium levels, muscle cramps; administer sodium chloride

Correct answer: A

Rationale: The correct signs of hyperkalemia include elevated potassium levels and muscle weakness. The treatment involves administering calcium gluconate to help stabilize the heart. Choice B is incorrect as hyperkalemia is characterized by elevated, not decreased, potassium levels. Choice C is incorrect as hyperkalemia does not involve elevated sodium levels, and the treatment is not sodium bicarbonate. Choice D is incorrect as hyperkalemia does not lead to low sodium levels, and sodium chloride is not the treatment for hyperkalemia.

3. A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?

• A. A client who was just given a glass of orange juice for a low blood glucose level.
• B. A client who is scheduled for a procedure in 1 hr.
• C. A client who has 100 mL fluid remaining in his IV bag.
• D. A client who received a pain medication 30 min ago for postoperative pain.

Correct answer: A

Rationale: The client with low blood glucose needs immediate assessment to ensure that the orange juice has corrected the hypoglycemia. Monitoring the effectiveness of the intervention for low blood glucose is the priority. The other options, such as a client scheduled for a procedure in 1 hour, a client with fluid remaining in the IV bag, and a client who received pain medication 30 minutes ago, do not require immediate assessment like the client with low blood glucose.

4. A client is receiving furosemide. Which of the following laboratory values should the nurse monitor?

• A. Sodium
• B. Potassium
• C. Calcium
• D. Magnesium

Correct answer: B

Rationale: The correct answer is B: Potassium. Furosemide is a loop diuretic that can cause potassium depletion through increased urinary excretion. Monitoring potassium levels is crucial to prevent hypokalemia, which can lead to cardiac dysrhythmias, muscle weakness, and other serious complications. Monitoring sodium, calcium, and magnesium levels is not typically associated with furosemide therapy, making choices A, C, and D incorrect.

5. A nurse is caring for a client who has pneumonia and new onset confusion. Which of the following actions should the nurse take first?

• A. Increase the client's oxygen flow rate
• B. Obtain the client's vital signs
• C. Administer an antibiotic
• D. Notify the provider

Correct answer: A

Rationale: Correct Answer: Increasing the client's oxygen flow rate should be the nurse's first action. Hypoxia is a common complication of pneumonia and can lead to confusion. Providing adequate oxygenation is essential in addressing hypoxia and improving the client's condition.\nOption B: Obtaining vital signs is important but addressing hypoxia takes precedence in the setting of new onset confusion.\nOption C: Administering an antibiotic is important for treating pneumonia but addressing hypoxia and confusion is the priority.\nOption D: Notifying the provider may be necessary but addressing the immediate physiological need of oxygenation should come first.

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