Nursing Elites

1. A client with chronic kidney disease (CKD) is experiencing hyperkalemia. Which intervention should the nurse implement to address this condition?

• A. Administer calcium gluconate.
• B. Encourage a diet high in potassium.
• C. Provide potassium supplements.
• D. Restrict sodium intake.

Correct answer: A

Rationale: Administering calcium gluconate is the appropriate intervention for a client with hyperkalemia. Calcium gluconate helps stabilize the heart by counteracting the effects of high potassium levels and reducing the risk of cardiac complications in individuals with hyperkalemia. Choices B, C, and D are incorrect. Encouraging a diet high in potassium or providing potassium supplements would exacerbate hyperkalemia. Restricting sodium intake is not directly related to addressing hyperkalemia.

2. A client with heart failure is prescribed digoxin (Lanoxin). Which instruction should the nurse include in the client's teaching plan?

• A. Take your pulse before each dose and hold the medication if your pulse is below 60 beats per minute.
• B. Increase your intake of foods high in potassium.
• C. Take the medication with a high-fiber meal to enhance absorption.
• D. Skip a dose if you feel dizzy or lightheaded.

Correct answer: A

Rationale: The correct instruction for a client prescribed digoxin is to take their pulse before each dose and hold the medication if the pulse is below 60 beats per minute. This is crucial to prevent digoxin toxicity, as digoxin can cause adverse effects when the pulse rate is too low. Monitoring the pulse regularly ensures safety and appropriate management of the medication.

3. In evaluating a 10-year-old child with meningitis suspected of having diabetes insipidus, which finding is indicative of diabetes insipidus?

• A. Decreased urine specific gravity.
• B. Elevated urine glucose.
• C. Decreased serum potassium.
• D. Increased serum sodium.

Correct answer: A

Rationale: Diabetes insipidus is characterized by the kidneys' inability to concentrate urine, leading to decreased urine specific gravity. This results in the excretion of large volumes of dilute urine, causing a decrease in urine specific gravity. Therefore, when evaluating a suspected case of diabetes insipidus, a finding of decreased urine specific gravity is indicative of this condition.

4. A client with type 1 diabetes mellitus is experiencing nausea and vomiting. What advice should the nurse give regarding insulin administration?

• A. Skip your insulin dose until you can eat.
• B. Take your insulin as prescribed, but monitor your blood glucose closely.
• C. Reduce your insulin dose by half.
• D. Only take your long-acting insulin.

Correct answer: B

Rationale: The correct advice for a client with type 1 diabetes mellitus experiencing nausea and vomiting is to take insulin as prescribed but monitor blood glucose closely. It is essential to continue insulin therapy even if not eating normally to prevent complications from high blood sugar levels. Skipping insulin doses can lead to dangerous fluctuations in blood glucose levels. Reducing the insulin dose without proper guidance can also result in uncontrolled blood sugar. Taking only long-acting insulin may not provide adequate coverage for mealtime blood sugar elevation. Therefore, the best course of action is to take prescribed insulin doses while closely monitoring blood glucose levels.

5. The healthcare provider is providing care to a client with a tracheostomy. Which action should the healthcare provider take to prevent tracheostomy complications?

• A. Use sterile technique when performing tracheostomy care.
• B. Suction the tracheostomy tube every hour.
• C. Keep the tracheostomy tube cuff inflated at all times.
• D. Change the tracheostomy ties daily.

Correct answer: A

Rationale: Using sterile technique when performing tracheostomy care is essential to prevent infections and other complications. Proper sterile technique helps reduce the risk of introducing harmful bacteria into the tracheostomy site, which can lead to infections and other serious issues. By maintaining a sterile environment during tracheostomy care, the healthcare provider can promote healing and prevent potential complications.

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