Nursing Elites

1. A client is wearing a continuous cardiac monitor, which begins to alarm at the nurse's station. The nurse sees no electrocardiographic complexes on the screen. What should the nurse do first?

• A. Call a code blue.
• B. Call the healthcare provider.
• C. Check the client's status and lead placement.
• D. Press the recorder button on the ECG console.

Correct answer: C

Rationale: The correct first action for the nurse to take is to check the client's status and lead placement. This step is crucial to ensure that the alarm is not triggered by a simple issue such as lead displacement. Calling a code blue (choice A) is premature without assessing the client first. Contacting the healthcare provider (choice B) can be done after ruling out basic causes for the alarm. Pressing the recorder button (choice D) is not as urgent as checking the client's status and lead placement in this scenario.

2. When preparing to administer a controlled substance, which of the following actions is required?

• A. Check the client's identification bracelet.
• B. Check the client's allergy status.
• C. Have a second nurse witness disposal of the medication.
• D. Document the administration in the client's medical record.

Correct answer: C

Rationale: When administering controlled substances, it is crucial to have a second nurse witness the disposal of the medication. This measure ensures proper handling, reduces the risk of diversion, and promotes compliance with regulations regarding controlled substances. Having a second nurse witness the disposal is a safeguard to maintain accountability and prevent any potential misuse or errors during the disposal process. Checking the client's identification bracelet and allergy status are important steps in medication administration but are not specifically required for controlled substances. Documenting the administration in the client's medical record is essential but does not specifically relate to the disposal of controlled substances.

3. A healthcare professional is reviewing laboratory results for a client who has been taking carbamazepine. Which of the following findings should the healthcare professional report to the provider?

• A. WBC count 3,000/mm3
• B. Platelet count 150,000/mm3
• C. Hemoglobin 14 g/dL
• D. Serum potassium 4.5 mEq/L

Correct answer: A

Rationale: A WBC count of 3,000/mm3 indicates leukopenia, a serious side effect of carbamazepine. Leukopenia can increase the risk of infections due to decreased white blood cell count, which is important to report to the provider for further evaluation and management. Platelet count within normal range (choice B), hemoglobin level within normal range (choice C), and serum potassium level within normal range (choice D) are not directly associated with carbamazepine use and do not require immediate reporting as they do not indicate a serious adverse effect.

4. A client with heart failure is prescribed furosemide (Lasix). The nurse should monitor the client for which potential electrolyte imbalance?

• A. Hyperkalemia
• B. Hypernatremia
• C. Hypokalemia
• D. Hypocalcemia

Correct answer: C

Rationale: When a client with heart failure is prescribed furosemide, the nurse should monitor for hypokalemia. Furosemide is a loop diuretic that can lead to potassium loss, which increases the risk of hypokalemia. Hypokalemia can have serious implications such as cardiac dysrhythmias. Therefore, it is essential to closely monitor the client's serum potassium levels while on furosemide to prevent complications. Hyperkalemia (Choice A) is incorrect because furosemide leads to potassium loss, not retention. Hypernatremia (Choice B) is not typically associated with furosemide use. Hypocalcemia (Choice D) is not a common electrolyte imbalance caused by furosemide.

5. The client with myocardial infarction should reduce intake of saturated fat and cholesterol. Which food items from the dietary menu would assist the nurse in helping the client comply with diet therapy?

• A. Cheeseburger, pan-fried potatoes, whole kernel corn, sherbet
• B. Pork chop, baked potato, cauliflower in cheese sauce, ice cream
• C. Baked haddock, steamed broccoli, herbed rice, sliced strawberries
• D. Spaghetti and sweet sausage in tomato sauce, vanilla pudding (with 4% milk)

Correct answer: C

Rationale: Option C, which includes baked haddock, steamed broccoli, herbed rice, and sliced strawberries, is the most appropriate choice for a client with myocardial infarction looking to reduce saturated fat and cholesterol intake. This meal is low in saturated fats and cholesterol, making it a heart-healthy option that aligns with the dietary recommendations for such clients. Choices A, B, and D contain foods high in saturated fats and cholesterol, which are not suitable for a client with myocardial infarction trying to adhere to a diet therapy aimed at reducing these components.

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