Nursing Elites

1. A client with cirrhosis is receiving spironolactone. What electrolyte level should the nurse monitor closely?

• A. Monitor potassium levels.
• B. Monitor sodium levels.
• C. Monitor calcium levels.
• D. Monitor magnesium levels.

Correct answer: A

Rationale: The correct answer is to monitor potassium levels. Spironolactone is a potassium-sparing diuretic, which means it helps the body retain potassium and excrete sodium. Monitoring potassium levels closely is essential because spironolactone can cause hyperkalemia (high potassium levels). Sodium levels are not typically affected by spironolactone. Calcium and magnesium levels are also not directly impacted by spironolactone, making choices B, C, and D incorrect.

2. A client with Addison's disease becomes confused and weak. What is the nurse's first action?

• A. Administer a dose of hydrocortisone immediately.
• B. Check the client’s electrolyte levels.
• C. Administer a dose of normal saline.
• D. Measure the client’s blood pressure in both arms.

Correct answer: A

Rationale: The correct answer is to administer a dose of hydrocortisone immediately. In Addison's disease, confusion and weakness can be signs of an adrenal crisis. Administering hydrocortisone promptly is crucial to prevent further deterioration. Checking electrolyte levels (Choice B) is important but not the first action in managing an acute adrenal crisis. Administering normal saline (Choice C) is not the priority in this situation. Measuring blood pressure in both arms (Choice D) is not the initial action needed to address the client's confusion and weakness in Addison's disease.

3. Prior to obtaining a trapeze bar for a client with limited mobility, which client assessment is most important for the nurse to obtain?

• A. Balance and coordination
• B. Cognitive status
• C. Level of pain
• D. Upper body muscle strength

Correct answer: D

Rationale: The correct answer is D: Upper body muscle strength. The ability to use a trapeze bar requires adequate upper body strength to support the weight and facilitate repositioning. While assessing pain, coordination, and cognitive status are important, the priority is determining if the client can physically manage the trapeze bar safely. Without sufficient upper body muscle strength, the client may not be able to use the trapeze bar effectively and safely. Assessing balance and coordination is also important but secondary to ensuring the client has the required upper body strength. Cognitive status is crucial for understanding instructions related to using the trapeze bar, but it is not the most critical assessment in this scenario. Pain assessment is essential for overall care but does not directly impact the client's ability to use a trapeze bar like upper body muscle strength does.

4. An older client is admitted with fluid volume deficit and dehydration. Which assessment finding is the best indicator of hydration status?

• A. Urine specific gravity of 1.040.
• B. Systolic blood pressure decreases by 10 points when standing.
• C. The client denies feeling thirsty.
• D. Skin turgor exhibits tenting on the forearm.

Correct answer: A

Rationale: In the context of fluid volume deficit and dehydration, urine specific gravity of 1.040 is the best indicator of hydration status. High urine specific gravity indicates concentrated urine, suggesting dehydration. Choice B, systolic blood pressure decreasing when standing, is more indicative of orthostatic hypotension rather than hydration status. Choice C, denial of thirst, is a subjective finding and may not always reflect actual hydration status. Choice D, skin turgor exhibiting tenting on the forearm, is a sign of dehydration but may not be as accurate as urine specific gravity in assessing hydration status.

5. After administering a proton pump inhibitor, which action should the nurse take to evaluate the effectiveness of the medication?

• A. Monitor gastrointestinal pain
• B. Ask the client about pain levels
• C. Check the client's vital signs
• D. Assess for signs of bleeding

Correct answer: B

Rationale: The correct answer is to ask the client about pain levels. Proton pump inhibitors (PPIs) work by reducing stomach acid to alleviate gastrointestinal pain. By inquiring about the client's pain experience, the nurse can directly assess the effectiveness of the medication. Monitoring bowel movements (Choice A) is not directly related to evaluating the effectiveness of a PPI. Checking vital signs (Choice C) may not reflect the medication's effectiveness in reducing stomach acid. Assessing for signs of bleeding (Choice D) is important but not the most direct way to evaluate the effectiveness of a PPI.

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