Nursing Elites

1. A client in heart failure (HF) presents with weakness and poor urine output. Which assessment finding requires immediate action?

• A. Heart rate of 122 bpm and respiratory rate of 28.
• B. Yellow sputum expectorated.
• C. Temperature of 100.5°F (38.1°C).
• D. Shortness of breath on exertion.

Correct answer: C

Rationale: An elevated temperature may indicate infection and should be treated immediately in a client with heart failure.

2. Which medication should the nurse withhold if the client's serum potassium level is 6.2 mEq/L?

• A. Losartan
• B. Spironolactone
• C. Metoprolol
• D. Furosemide

Correct answer: B

Rationale: The correct answer is B: Spironolactone. Spironolactone is a potassium-sparing diuretic that can lead to hyperkalemia. With potassium levels already elevated at 6.2 mEq/L, withholding Spironolactone is essential to prevent further increase in potassium levels, which could result in dangerous cardiac arrhythmias. Losartan (Choice A) is an angiotensin receptor blocker and does not directly affect potassium levels. Metoprolol (Choice C) is a beta-blocker and also does not impact potassium levels significantly. Furosemide (Choice D) is a loop diuretic that can actually lower potassium levels, so it would not be the medication to withhold in this case.

3. A male client with cirrhosis has jaundice and pruritus. He tells the nurse that he has been soaking in hot baths at night with no relief of his discomfort. Which action should the nurse take?

• A. Instruct the client to use a moisturizer immediately after the bath
• B. Advise the client to take shorter baths with less water
• C. Suggest taking antihistamines for the pruritus
• D. Encourage the client to use cooler water and apply calamine lotion after soaking

Correct answer: D

Rationale: In this situation, the client's pruritus (itching) is likely exacerbated by hot baths, which can worsen the itching sensation. Using cooler water will help soothe the skin and reduce pruritus. Additionally, applying calamine lotion after soaking can provide further relief. Instructing the client to use a moisturizer immediately after the bath (Choice A) may not address the root cause of pruritus aggravated by hot baths. Advising the client to take shorter baths with less water (Choice B) might not be as effective in relieving the itching sensation caused by cirrhosis. Suggesting antihistamines for the pruritus (Choice C) may not directly address the impact of hot baths on the client's discomfort.

4. The nurse is caring for a group of clients with the help of a PN. Which nursing actions should the nurse assign to the PN?

• A. All of the above
• B. Administer a dose of insulin per sliding scale for a client with Type 2 DM
• C. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty
• D. Perform daily surgical dressing change for a client who had an abdominal hysterectomy

Correct answer: A

Rationale: All of these tasks fall within the PN's scope of practice, which includes performing surgical dressing changes, taking postoperative vital signs, and administering insulin under supervision. The RN can delegate these tasks to the PN safely. Choice A is the correct answer because all the tasks mentioned are appropriate for delegation to a PN. Choice B should not be assigned to a PN as only RNs should administer insulin. Choice C is suitable for delegation to a PN as obtaining vital signs falls within their scope of practice. Choice D is also appropriate for delegation to a PN as performing surgical dressing changes is within their scope of practice.

5. A client with a history of chronic kidney disease presents with increased swelling and shortness of breath. What is the nurse's priority action?

• A. Administer oxygen at 2 liters per nasal cannula.
• B. Administer a diuretic as prescribed.
• C. Monitor the client's vital signs.
• D. Reposition the client to improve lung expansion.

Correct answer: B

Rationale: The correct answer is to administer a diuretic as prescribed. In a client with chronic kidney disease experiencing increased swelling and shortness of breath, the priority action is to address fluid retention. Administering a diuretic helps reduce fluid overload, alleviate symptoms, and prevent complications associated with fluid buildup. Option A is not the priority in this situation as addressing fluid retention takes precedence over providing oxygen. While monitoring vital signs is important, it is secondary to addressing the underlying cause of symptoms. Repositioning the client may help with comfort but does not directly address the fluid overload seen in chronic kidney disease.

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