Nursing Elites

1. A client with heart failure is prescribed furosemide. The nurse notes that the client's potassium level is 3.1 mEq/L. What is the nurse's priority action?

• A. Administer a potassium supplement
• B. Encourage the client to eat potassium-rich foods
• C. Hold the next dose of furosemide
• D. Increase the client's fluid intake

Correct answer: A

Rationale: A potassium level of 3.1 mEq/L is considered low, indicating hypokalemia. Administering a potassium supplement is the nurse's priority action to prevent complications such as cardiac arrhythmias associated with low potassium levels. Encouraging the client to eat potassium-rich foods is beneficial in the long term but may not rapidly correct the low potassium level. Holding the next dose of furosemide may worsen the client's heart failure symptoms. Increasing the client's fluid intake is not the priority action in this situation; addressing the low potassium level takes precedence to prevent potential serious complications.

2. The nurse observes that a client’s wrist restraint is secured to the side rail of the bed. What action should the nurse take?

• A. Ensure that the restraint is snug against the client’s wrist.
• B. Reposition the restraint tie onto the bedframe.
• C. Double knot the restraint to ensure safety.
• D. Leave the restraint in place and notify the healthcare provider.

Correct answer: B

Rationale: The correct action for the nurse to take is to reposition the restraint tie onto the bedframe. Restraints should always be secured to the bedframe, not the side rails, to prevent injury to the client in case the bed is adjusted. Choice A is incorrect because the issue is with the attachment point, not the snugness of the restraint. Choice C is incorrect as double knotting the restraint does not address the incorrect attachment point. Choice D is incorrect as the nurse should not leave the restraint in the wrong position; instead, it should be moved to the correct location on the bedframe.

3. While assessing a client who is admitted with heart failure and pulmonary edema, the nurse identifies dependent peripheral edema, an irregular heart rate, and a persistent cough that produces pink blood-tinged sputum. After initiating continuous telemetry and positioning the client, which intervention should the nurse implement?

• A. Administer prescribed diuretics
• B. Prepare for intubation
• C. Notify the healthcare provider immediately
• D. Obtain sputum sample

Correct answer: D

Rationale: The client's cough producing pink, frothy sputum is indicative of pulmonary edema, which needs immediate treatment. Obtaining a sputum sample helps identify any infection that may be contributing to the pulmonary issues. Administering diuretics is essential in managing pulmonary edema but obtaining a sputum sample should take priority. Intubation may be necessary in severe cases but is not the initial intervention. Notifying the healthcare provider is important, but immediate action to diagnose and treat the condition is crucial.

4. A client with heart failure is receiving furosemide. What assessment finding indicates the medication is effective?

• A. Increased urine output and weight loss.
• B. Increased heart rate and blood pressure.
• C. Decreased edema and improved peripheral pulses.
• D. Decreased shortness of breath and clear lung sounds.

Correct answer: C

Rationale: The correct answer is C: 'Decreased edema and improved peripheral pulses.' In a client with heart failure, furosemide is a diuretic that helps reduce fluid overload. Therefore, a decrease in edema (swelling due to fluid retention) and improved peripheral pulses (indicating better circulation) are signs that the medication is effective. Choices A, B, and D are incorrect. Increased urine output and weight loss (Choice A) may indicate the diuretic effect of furosemide but do not specifically reflect its effectiveness in heart failure. Increased heart rate and blood pressure (Choice B) are not desired effects of furosemide and may suggest adverse reactions. Decreased shortness of breath and clear lung sounds (Choice D) are related to improved respiratory status and may not directly reflect the effectiveness of furosemide in addressing fluid overload.

5. An unlicensed assistive personnel (UAP), who usually works on a surgical unit, is assigned to float to a pediatric unit. Which question by the charge nurse would be most appropriate when making delegation decisions?

• A. How long have you been a UAP and what units have you worked on?
• B. What type of care do you provide on the surgical unit, and what are the ages of the clients?
• C. What is your comfort level in caring for children and at what ages?
• D. Have you reviewed the list of expected skills you might need on this unit?

Correct answer: D

Rationale: The most appropriate question by the charge nurse would be to ask the UAP if they have reviewed the list of expected skills needed on the pediatric unit. This ensures that the UAP is aware of the specific skills required for safe and appropriate care in that particular unit. Choices A, B, and C do not directly address the need for the UAP to review the expected skills, which is crucial for delegation decisions during floating assignments.

Similar Questions