Nursing Elites

1. A client with heart failure who is on a low sodium diet reports a weight gain of 2 kg in 24 hours. Which intervention should the nurse implement first?

• A. Instruct the client to reduce fluid intake
• B. Monitor the client's intake and output
• C. Administer a diuretic as prescribed
• D. Assess the client for signs of fluid overload

Correct answer: D

Rationale: The correct first intervention for a client with heart failure who is on a low sodium diet and reports a significant weight gain is to assess the client for signs of fluid overload. This step is crucial in determining the severity of the situation and guiding further treatment. In this scenario, assessing for signs of fluid overload takes priority over other actions such as instructing the client to reduce fluid intake, monitoring intake and output, or administering a diuretic. While these actions may be necessary depending on the assessment findings, the initial priority is to evaluate the client's immediate condition.

2. The nurse needs to add a medication to a liter of 5% Dextrose in Water (D5W) that is already infusing into a client. At what location should the nurse inject the medication?

• A. Medication port
• B. IV drip chamber
• C. Y-site connector
• D. At the hub of the IV catheter

Correct answer: A

Rationale: The correct answer is the medication port. When adding medication to an already infusing IV solution, it should be done through the medication port to ensure direct delivery into the bloodstream without interrupting the primary IV line. Injecting the medication into the IV drip chamber, Y-site connector, or at the hub of the IV catheter can lead to dilution, inaccurate dosing, or potential blockages in the IV line, which can compromise the effectiveness of the medication and patient safety.

3. A client with end-stage renal disease (ESRD) is scheduled for hemodialysis. Which laboratory value should be reported to the healthcare provider before the procedure?

• A. Serum creatinine of 2.5 mg/dL
• B. Serum potassium of 6.5 mEq/L
• C. Serum calcium of 8 mg/dL
• D. Serum bicarbonate of 24 mEq/L

Correct answer: B

Rationale: The correct answer is B. A serum potassium level of 6.5 mEq/L is dangerously high and should be reported before hemodialysis to prevent cardiac complications. High potassium levels can lead to life-threatening arrhythmias. Serum creatinine (Choice A) is elevated in renal dysfunction but not the most critical value to report before hemodialysis. Serum calcium (Choice C) and serum bicarbonate (Choice D) levels are within normal limits and are not immediate concerns before hemodialysis.

4. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which finding indicates the need for immediate intervention?

• A. Use of accessory muscles
• B. Oxygen saturation of 94%
• C. Carbon dioxide level of 45 mmHg
• D. Respiratory rate of 20 breaths per minute

Correct answer: C

Rationale: A carbon dioxide level of 45 mmHg is concerning in a client with COPD receiving supplemental oxygen, as it may indicate carbon dioxide retention and requires immediate intervention. Options A, B, and D are not the priority findings in this scenario. While the use of accessory muscles, an oxygen saturation of 94%, and a respiratory rate of 20 breaths per minute are important to monitor in a client with COPD, they do not indicate an immediate need for intervention like an elevated carbon dioxide level does.

5. A client with hyperthyroidism is admitted to the postoperative unit after subtotal thyroidectomy. Which of the client's serum laboratory values requires intervention by the nurse?

• A. Total calcium 5.0 mg/dL.
• B. Serum sodium 140 mEq/L.
• C. Serum potassium 4.0 mEq/L.
• D. Serum glucose 90 mg/dL.

Correct answer: A

Rationale: The correct answer is A. A calcium level of 5.0 mg/dL is critically low and could indicate hypoparathyroidism, a possible complication after thyroidectomy. Low calcium levels can lead to tetany, seizures, and cardiac dysrhythmias, requiring immediate intervention. Choices B, C, and D fall within the normal range and do not require immediate intervention in this scenario.

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