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 is developing a teaching plan for a client receiving chemotherapy. Which of the following should be the nurse's first priority?

• A. The client will maintain adequate nutrition.
• B. The client will manage side effects of treatment.
• C. The client will recognize signs and symptoms of infection.
• D. The client will experience a reduction in pain.

Correct answer: C

Rationale: The correct answer is C. Recognizing signs and symptoms of infection should be the nurse's first priority when developing a teaching plan for a client receiving chemotherapy. Chemotherapy often compromises the immune system, making patients more susceptible to infections. Early identification and prompt treatment of infections are crucial to prevent complications. Options A, B, and D are important aspects of care but recognizing signs of infection takes precedence due to the potential life-threatening consequences in clients undergoing chemotherapy treatment.

3. A client with anemia is prescribed iron supplements. What teaching should the nurse provide?

• A. Take iron supplements with meals to prevent stomach upset.
• B. Take iron supplements with milk to improve absorption.
• C. Expect black, tarry stools as a side effect of iron supplements.
• D. Take iron supplements with vitamin C to improve absorption.

Correct answer: D

Rationale: The correct answer is D: Take iron supplements with vitamin C to improve absorption. Vitamin C enhances iron uptake, making it more bioavailable for the body. It is essential to avoid taking iron supplements with milk (choice B) as calcium-rich foods can hinder iron absorption. Taking iron supplements with meals (choice A) can help reduce stomach upset, but the optimal way to enhance absorption is with vitamin C. Black, tarry stools (choice C) are not a typical side effect of iron supplements and should be reported to the healthcare provider.

4. A client presses the call bell and requests pain medication for a severe headache. To assess the quality of the client's pain, which approach should the nurse use?

• A. Use the Wong-Baker Faces pain rating scale
• B. Assess vital signs to gauge pain severity
• C. Ask the client to describe the pain
• D. Offer a 1-10 pain scale

Correct answer: C

Rationale: Asking the client to describe the pain is the most appropriate approach to assess the quality of pain. It provides valuable qualitative information that aids in understanding the nature, cause, and potential management strategies for the headache. While pain rating scales like the Wong-Baker Faces scale and using vital signs can help quantify pain severity, they do not offer specific descriptive details that can give insights into the type and characteristics of the pain experienced by the client.

5. The nurse is preparing to administer an intramuscular injection to an adult client. Which site should the nurse select?

• A. Deltoid muscle
• B. Ventrogluteal muscle
• C. Vastus lateralis muscle
• D. Dorsogluteal muscle

Correct answer: B

Rationale: The ventrogluteal site is preferred for intramuscular injections in adults because it is free from major blood vessels and nerves, reducing the risk of injury. The deltoid muscle can be used for smaller volumes of medication, primarily vaccines. The vastus lateralis muscle is commonly used in infants, toddlers, and young children. The dorsogluteal muscle site is discouraged due to its proximity to the sciatic nerve, increasing the risk of injury or nerve damage.

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