Nursing Elites

1. A client has a serum potassium level of 6.5 mmol/L, a serum creatinine level of 2 mg/dL, and a urine output of 350 mL/day. What is the best action by the nurse?

• A. Place the client on a cardiac monitor immediately.
• B. Teach the client to limit high-potassium foods.
• C. Continue to monitor the client’s intake and output.
• D. Ask to have the laboratory redraw the blood specimen.

Correct answer: A

Rationale: The best immediate action by the nurse in this situation is to place the client on a cardiac monitor immediately. A serum potassium level of 6.5 mmol/L indicates hyperkalemia, which can lead to life-threatening dysrhythmias. Monitoring the cardiac status is crucial to detect any potential arrhythmias promptly. Teaching the client to limit high-potassium foods (Choice B) may be important for long-term management, but it is not the priority at this moment. Continuing to monitor intake and output (Choice C) is important for assessing renal function but does not address the immediate risk of dysrhythmias. Asking to have the laboratory redraw the blood specimen (Choice D) is unnecessary since the current results indicate a critical situation that requires immediate action.

2. A client is vomiting. For which acid-base imbalance does the nurse assess the client?

• A. Metabolic acidosis
• B. Metabolic alkalosis
• C. Respiratory acidosis
• D. Respiratory alkalosis

Correct answer: B

Rationale: In a client who is vomiting, the loss of gastric fluid containing hydrochloric acid can lead to metabolic alkalosis. Metabolic alkalosis is caused by the loss of acids such as hydrochloric acid from the body. Therefore, in this scenario, the nurse should assess the client for metabolic alkalosis. Choices A, C, and D are incorrect because vomiting does not typically lead to metabolic acidosis, respiratory acidosis, or respiratory alkalosis.

3. When conducting discharge teaching for a client diagnosed with diverticulitis, which diet instruction should the nurse include?

• A. Have small, frequent meals and sit up for at least two hours after meals
• B. Eat a bland diet and avoid spicy foods
• C. Eat a high-fiber diet and increase fluid intake
• D. Eat a soft diet with increased intake of milk and milk products

Correct answer: C

Rationale: For a client diagnosed with diverticulitis, the nurse should instruct them to eat a high-fiber diet and increase fluid intake. This diet helps in managing diverticulitis by promoting bowel regularity and preventing complications such as diverticular inflammation or infection. Choice A of having small, frequent meals and sitting up for at least two hours after meals may be beneficial for gastroesophageal reflux disease but is not specific to diverticulitis. Choice B of eating a bland diet and avoiding spicy foods is not the preferred recommendation for diverticulitis management. Choice D of eating a soft diet with increased intake of milk and milk products may not provide enough fiber to aid in diverticulitis management, and the increased intake of dairy products may worsen symptoms in some individuals.

4. A healthcare professional reviews a client’s laboratory results. Which results from the client’s urinalysis should the healthcare professional identify as normal? (Select all that apply.)

• A. pH: 6
• B. Specific gravity: 1.015
• C. Glucose: negative
• D. All of the above

Correct answer: D

Rationale: In a urinalysis, a pH of 6 is within the normal range (typically between 4.6 and 8); a specific gravity of 1.015 is considered normal (usually ranging between 1.005 to 1.030); and a negative glucose result is also normal. Therefore, choices A, B, and C are correct as they fall within the normal values for a urinalysis. Choices A, B, and C are the correct answers, as the pH, specific gravity, and glucose levels are within the normal range for a urinalysis. Choice D is correct because all the listed values are normal. Choices A, B, and C are the correct options as they meet the criteria for normal urinalysis values. The other choices do not fall within the normal range for a urinalysis.

5. A client tells the nurse that he has been experiencing frequent heartburn and has been 'living on antacids.' For which acid-base disturbance does the nurse recognize a risk?

• A. Metabolic acidosis
• B. Metabolic alkalosis
• C. Respiratory acidosis
• D. Respiratory alkalosis

Correct answer: B

Rationale: The correct answer is B: Metabolic alkalosis. In this scenario, the client's frequent use of antacids containing alkaline components can lead to an excess of bicarbonate in the body, causing metabolic alkalosis. Oral antacids work by neutralizing stomach acid, potentially leading to an alkaline shift in the body's pH balance. Choices A, C, and D are incorrect. Metabolic acidosis is not typically associated with antacid use. Respiratory acidosis and respiratory alkalosis are related to respiratory system dysfunction rather than antacid ingestion.

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