Nursing Elites

1. A client with a diagnosis of heart failure is receiving furosemide (Lasix). Which electrolyte imbalance should the nurse monitor for?

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

Correct answer: D

Rationale: The correct answer is D: Hypokalemia. Furosemide is a loop diuretic that can cause potassium loss, leading to hypokalemia. Therefore, the nurse should monitor the client for low potassium levels. Choice A, Hyperkalemia, is incorrect as furosemide does not typically cause high potassium levels. Choice B, Hyponatremia, is incorrect as furosemide primarily affects potassium levels, not sodium. Choice C, Hypocalcemia, is incorrect as furosemide does not directly impact calcium levels.

2. A client is admitted with a diagnosis of congestive heart failure (CHF). Which intervention is most important to include in the plan of care?

• A. Restrict fluid intake
• B. Provide a high-sodium diet
• C. Encourage vigorous exercise
• D. Administer bronchodilators as prescribed

Correct answer: A

Rationale: The correct answer is A: Restrict fluid intake. Fluid restriction is crucial in the management of congestive heart failure (CHF) as it helps prevent fluid overload, which can exacerbate CHF symptoms. Choices B, C, and D are incorrect. Providing a high-sodium diet would worsen fluid retention and increase the workload of the heart. Encouraging vigorous exercise can strain the heart further in CHF patients. Administering bronchodilators is not the priority intervention for CHF.

3. A nurse is developing a care plan for a client with chronic pain. What interventions should be included to help manage pain?

• A. Administer pain medication around the clock
• B. Teach relaxation techniques
• C. Encourage physical activity
• D. All of the above

Correct answer: D

Rationale: In managing chronic pain, it is essential to employ a multi-faceted approach. Administering pain medication around the clock helps maintain consistent pain relief. Teaching relaxation techniques such as deep breathing or guided imagery can help reduce muscle tension and promote relaxation, which can alleviate pain. Encouraging physical activity, tailored to the client's abilities, can help improve overall physical functioning and reduce pain perception. Therefore, combining all these interventions (pain medication, relaxation techniques, and physical activity) provides a comprehensive approach to pain management, addressing different aspects of the client's experience with chronic pain. This holistic approach is more effective than using a single intervention alone, making 'All of the above' the correct choice.

4. A client has a prescription for enteric-coated (EC) aspirin 325mg PO daily. The medication drawer contains one 325mg aspirin. What action should the nurse take?

• A. Contact the pharmacy and request the prescribed form of aspirin
• B. Instruct the client about the effects of the medication
• C. Administer the aspirin with a full glass of water or a small snack
• D. Withhold the aspirin until consulting with the healthcare provider

Correct answer: A

Rationale: The correct action for the nurse to take is to contact the pharmacy and request the prescribed form of aspirin. Enteric-coated medications are designed to dissolve in the intestine, not the stomach, to avoid irritation. Therefore, it is essential to ensure the client receives the correct form of aspirin as prescribed. Instructing the client about the effects of the medication (choice B) is not necessary at this point as the issue is related to the form of the aspirin. Administering the aspirin with a full glass of water or a small snack (choice C) is not appropriate as it does not address the need for the correct form of the medication. Withholding the aspirin (choice D) without consulting the healthcare provider is not advisable as it may lead to a delay in the client receiving the necessary medication.

5. What safety measure should be implemented when administering chemotherapy?

• A. Use protective gloves and gown
• B. Prepare the medication in a designated area
• C. Administer the medication at the appropriate rate
• D. Verify the two client identifiers

Correct answer: A

Rationale: When administering chemotherapy, it is crucial to use protective gloves and a gown to protect against exposure to hazardous drugs that can be harmful through skin contact. Choice B is incorrect because chemotherapy medication should be prepared in a designated area to prevent contamination and ensure accurate preparation. Choice C is incorrect as chemotherapy should be administered at the appropriate rate to ensure patient safety and avoid adverse effects. Choice D is incorrect as verifying client identifiers is important for medication administration in general but not a specific safety measure related to chemotherapy administration.

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