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. The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be a priority for the nurse to report to the health care provider?

• A. Oral temperature of 100.1°F
• B. Serum sodium level of 138 mEq/L (138 mmol/L)
• C. Gradually decreasing level of consciousness (LOC)
• D. Weight gain of 2 pounds (1 kg) above the admission weight

Correct answer: C

Rationale: The priority assessment finding for the nurse to report to the healthcare provider is a gradually decreasing level of consciousness (LOC). This change in LOC could indicate fluid and electrolyte disturbances, which require immediate attention to prevent complications. While the other options such as an elevated temperature, serum sodium level, and weight gain are important to note and report, they do not indicate an urgent need for intervention compared to changes in LOC which could signify serious issues that need prompt evaluation and management.

3. A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the healthcare provider immediately that the patient is on which medication?

• A. Oral digoxin (Lanoxin) 0.25 mg daily
• B. Ibuprofen (Motrin) 400 mg every 6 hours
• C. Metoprolol (Lopressor) 12.5 mg orally daily
• D. Lantus insulin 24 U subcutaneously every evening

Correct answer: A

Rationale: The correct answer is A. Hypokalemia increases the risk for digoxin toxicity, which can lead to serious dysrhythmias. Therefore, with a low potassium level, the nurse should immediately alert the healthcare provider about the patient being on oral digoxin. Choices B, C, and D do not pose as much concern with the given potassium level. However, further assessment is still required for these medications.

4. The nurse requests a meal tray for a client who follows Mormon beliefs and who is on a clear liquid diet following abdominal surgery. Which menu items should the nurse request for this client? (Select all that apply)

• A. apple juice
• B. black coffee
• C. orange juice
• D. hot chocolate

Correct answer: A

Rationale: The correct answer is A: apple juice. Clear liquids like apple juice and orange juice are suitable for a client following a clear liquid diet and Mormon beliefs. Options B and D, black coffee and hot chocolate, contain caffeine, which may not align with the client's religious dietary restrictions. Therefore, these options should be avoided for this client.

5. A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question?

• A. Infuse 5% dextrose in water at 125 mL/hr.
• B. Administer IV morphine sulfate 4 mg every 2 hours PRN.
• C. Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea.
• D. Administer 3% saline if serum sodium decreases to less than 128 mEq/L.

Correct answer: A

Rationale: The nurse should question the prescription to infuse 5% dextrose in water at 125 mL/hr because the patient's gastric suction has been depleting electrolytes, leading to hyponatremia. Therefore, the IV solution should include electrolyte replacement. Solutions like lactated Ringer’s solution would usually be ordered. The other choices (B, C, and D) are appropriate for a postoperative patient with gastric suction, addressing pain management, nausea control, and correcting hyponatremia if it drops below a certain level.

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