Nursing Elites

1. Which of the following assessments is the most important for a patient receiving IV potassium?

• A. Respiratory rate
• B. Heart rate
• C. Blood pressure
• D. Oxygen saturation

Correct answer: C

Rationale: The most important assessment for a patient receiving IV potassium is monitoring blood pressure. IV potassium can cause significant changes in cardiac function, leading to adverse effects such as arrhythmias and cardiac arrest. While respiratory rate, heart rate, and oxygen saturation are important parameters to monitor in clinical practice, blood pressure takes precedence in patients receiving IV potassium due to its direct impact on cardiovascular function. Changes in blood pressure can be an early indicator of potassium-induced cardiac complications, making it crucial to monitor closely during administration.

2. The client with chronic renal failure asks why a low-protein diet is necessary. Which of the following is the best response by the nurse?

• A. It reduces the workload on your kidneys.
• B. It helps prevent the buildup of waste products.
• C. It helps maintain electrolyte balance in your body.
• D. It helps prevent dehydration.

Correct answer: B

Rationale: A low-protein diet is necessary for clients with chronic renal failure to help prevent the buildup of waste products, such as urea, in the body. Choice A is incorrect as the primary reason for a low-protein diet is to manage waste product accumulation rather than reducing the workload on the kidneys. Choice C is incorrect as electrolyte balance is typically managed through dietary restrictions beyond protein intake. Choice D is incorrect as preventing dehydration is not the primary purpose of a low-protein diet in chronic renal failure.

3. The nurse is preparing to administer an antibiotic to a patient who has been receiving the antibiotic for 2 days after a culture was obtained. The nurse notes increased erythema and swelling, and the patient has a persistent high fever of 39°C. What is the nurse’s next action?

• A. Administer the antibiotic as ordered.
• B. Contact the provider to request another culture.
• C. Discuss the need to add a second antibiotic with the provider.
• D. Review the sensitivity results from the patient’s culture.

Correct answer: D

Rationale: In this scenario, the nurse is observing signs of a possible lack of response to the current antibiotic therapy, such as increased erythema, swelling, and persistent high fever. The next appropriate action for the nurse is to review the sensitivity results from the patient’s culture. This step is crucial to determine if the current antibiotic is effective against the causative organism. If the sensitivity results indicate resistance to the current antibiotic, the antibiotic should be discontinued, and the provider should be notified for a change in therapy. Contacting the provider to request another culture is not the immediate priority, as the existing culture results need to be reviewed first. Adding a second antibiotic should only be considered after confirming the sensitivity results, as unnecessary antibiotic use can lead to antimicrobial resistance.

4. The healthcare provider is assessing a client with chronic renal failure who is receiving hemodialysis. Which of the following findings would indicate that the client is experiencing a complication of the treatment?

• A. Clear dialysate outflow.
• B. Blood pressure of 150/90 mm Hg.
• C. Increased heart rate.
• D. Fatigue.

Correct answer: B

Rationale: A blood pressure of 150/90 mm Hg during hemodialysis may indicate fluid overload or an ineffective dialysis session, which can lead to complications such as heart failure or pulmonary edema. This finding should be reported promptly for further evaluation and intervention. Clear dialysate outflow is a normal and expected finding during hemodialysis, indicating proper filtration of waste products. Increased heart rate can be a normal compensatory response to hemodialysis due to fluid shifts and should be monitored but does not necessarily indicate a complication. Fatigue is a common symptom in clients with chronic renal failure undergoing hemodialysis and is not specific to complications of the treatment.

5. What is the primary purpose of administering anticoagulants to a patient with atrial fibrillation?

• A. To reduce blood pressure.
• B. To prevent clot formation.
• C. To prevent arrhythmias.
• D. To reduce inflammation.

Correct answer: B

Rationale: The primary purpose of administering anticoagulants to a patient with atrial fibrillation is to prevent clot formation. Patients with atrial fibrillation are at an increased risk of forming blood clots in the heart, which can lead to stroke if they travel to the brain. Anticoagulants help to reduce this risk by inhibiting the clotting process. Therefore, choices A, C, and D are incorrect because anticoagulants do not primarily aim to reduce blood pressure, prevent arrhythmias, or reduce inflammation in patients with atrial fibrillation.

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