Nursing Elites

1. A 54-year-old male client and his wife were informed this morning that he has terminal cancer. Which nursing intervention is likely to be most beneficial?

• A. Ask the wife how she would like to participate in the client's care
• B. Provide the wife with information about hospice
• C. Encourage the wife to visit after painful treatments are completed
• D. Refer the wife to a support group for family members of those dying of cancer

Correct answer: A

Rationale: The most beneficial nursing intervention in this situation is to ask the wife how she would like to participate in the client's care. Involving the spouse in the care of the terminally ill client can provide comfort, support, and a sense of contribution during a challenging time. Providing information about hospice (B) is important but may not be the immediate priority. Encouraging the wife to visit after treatments are completed (C) may delay her involvement in the care. Referring her to a support group (D) is a good idea but might be more suitable at a later stage.

2. A newly admitted patient is diagnosed with hyponatremia. When making room assignments, the charge nurse should take which action?

• A. Assign the patient to a room near the nurse’s station.
• B. Place the patient in a room nearest to the water fountain.
• C. Place the patient on telemetry to monitor for peaked T waves.
• D. Assign the patient to a semi-private room and place an order for a low-salt diet.

Correct answer: A

Rationale: The correct answer is A. The patient should be placed near the nurse’s station if confused to allow close monitoring by the staff. To help improve serum sodium levels, water intake is restricted, so a patient with hyponatremia should not be placed near a water fountain. Peaked T waves are a sign of hyperkalemia, not hyponatremia, so telemetry for this purpose is unnecessary. Placing a confused patient in a semi-private room could be disruptive to the other patient. Additionally, the patient needs sodium replacement, not a low-salt diet.

3. The nurse is caring for a patient who has a central venous access device (CVAD). Which action by the nurse is appropriate?

• A. Avoid using friction when cleaning around the CVAD insertion site.
• B. Use the push-pause method to flush the CVAD after giving medications.
• C. Obtain an order from the healthcare provider to change the CVAD dressing.
• D. Position the patient’s face away from the CVAD during injection cap changes.

Correct answer: B

Rationale: The correct answer is B because using the push-pause method to flush the CVAD after giving medications helps remove debris from the CVAD lumen and decreases the risk for clotting. Choice A is incorrect because friction should be used when cleaning the CVAD insertion site to decrease infection risk. Choice C is incorrect because obtaining an order from the healthcare provider to change the CVAD dressing is not necessary; the dressing should be changed when damp, loose, or visibly soiled. Choice D is incorrect because the patient should face away from the CVAD during cap changes to minimize the risk of contamination.

4. When assessing a male client, the nurse finds that he is fatigued, and is experiencing muscle weakness, leg cramps, and cardiac dysrhythmias. Based on these findings, the nurse plans to check the client's laboratory values to validate the existence of which?

• A. Hyperphosphatemia
• B. Hypocalcemia
• C. Hypermagnesemia
• D. Hypokalemia

Correct answer: D

Rationale: The correct answer is D, Hypokalemia. Generalized weakness, muscle weakness, leg cramps, and cardiac dysrhythmias are manifestations of hypokalemia. Checking the potassium level is essential in this case. Hypocalcemia typically presents with facial muscle spasms, not the symptoms mentioned. Hypermagnesemia does not typically cause the symptoms described. It's important to note that orange juice is high in potassium and would be advisable to drink if the patient was hypokalemic. Loose stools are more commonly associated with hyperkalemia, not hypokalemia.

5. An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately?

• A. K+ 3.4 mEq/L (3.4 mmol/L)
• B. Ca+2 7.8 mg/dL (1.95 mmol/L)
• C. Na+ 154 mEq/L (154 mmol/L)
• D. PO4-3 4.8 mg/dL (1.55 mmol/L)

Correct answer: C

Rationale: The correct answer is C. The elevated serum sodium level (154 mEq/L) is consistent with the patient's neurologic symptoms of restlessness, agitation, and weakness, indicating a need for immediate action to prevent complications like seizures. The potassium level (3.4 mEq/L) and calcium level (7.8 mg/dL) are slightly off from normal but do not require immediate action. The phosphate level (4.8 mg/dL) is normal and not related to the symptoms presented by the patient.

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