Nursing Elites

1. While caring for a client in a clinic, a healthcare professional learns that the client woke up not recognizing their partner, surroundings, has chills, and chest pain worsening upon inspiration. What should be the healthcare professional's priority action?

• A. Obtain baseline vital signs and oxygen saturation.
• B. Obtain a sputum culture.
• C. Obtain a complete history from the client.
• D. Provide a pneumococcal vaccine.

Correct answer: A

Rationale: The priority action for the healthcare professional is to obtain the client's baseline vital signs and oxygen saturation. This will provide essential information on the client's current physiological status and help guide further assessment and intervention. Assessing the vital signs and oxygen saturation can help identify any immediate concerns like hypoxia or sepsis, which require prompt attention. While obtaining a complete history and considering a pneumococcal vaccine may be important in the overall care of the client, assessing the vital signs and oxygen saturation takes precedence to address the client's immediate physiological needs.

2. A client with tuberculosis is receiving a new prescription for isoniazid (INH). The nurse should instruct the client to report which of the following findings as an adverse effect of the medication?

• A. You might notice yellowing of your skin.
• B. You might experience pain in your joints.
• C. You might notice tingling of your hands.
• D. You might experience loss of appetite.

Correct answer: C

Rationale: Tingling of the hands is a common adverse effect of isoniazid (INH) due to its potential to cause peripheral neuropathy. This sensation can be an early sign of nerve damage, and thus, the client should be instructed to report it promptly to the healthcare provider for further evaluation and management.

3. When providing discharge teaching for a group of clients, a nurse should recommend a referral to a dietitian for which client?

• A. A client who has a prescription for warfarin and states, 'I will need to limit how much spinach I eat.'
• B. A client who has gout and states, 'I can continue to eat anchovies on my pizza.'
• C. A client who has a prescription for spironolactone and states, 'I will reduce my intake of foods that contain potassium.'
• D. A client who has osteoporosis and states, 'I'll plan to take my calcium carbonate with a full glass of water.'

Correct answer: B

Rationale: The correct answer is the client who has gout and states, 'I can continue to eat anchovies on my pizza.' Gout is a condition that requires dietary modifications to manage symptoms. Anchovies are high in purines, which can exacerbate gout symptoms. Therefore, a referral to a dietitian is essential to provide appropriate dietary guidance for a client with gout. Clients on warfarin may need to monitor their vitamin K intake, particularly from foods like spinach. Clients taking spironolactone should be cautious about potassium-rich foods. Clients with osteoporosis should be educated on the proper administration of calcium supplements but do not necessarily need a dietitian referral for this specific statement.

4. During a shift change, a nurse is receiving a report for an adult female client who is postoperative. Which of the following client information should the nurse report?

• A. High platelets
• B. Hypertension
• C. Lower platelets
• D. High temperatures

Correct answer: C

Rationale: Lower platelets can indicate a potential risk of bleeding in a postoperative client. Thrombocytopenia, or low platelet count, can lead to increased bleeding tendencies and should be promptly reported to the healthcare team for appropriate management. Monitoring platelet levels is crucial in postoperative care to prevent complications related to inadequate clotting ability.

5. After 1 week of hospitalization, Mr. Gray develops hypokalemia. Which of the following is the most significant symptom of his disorder?

• A. Lethargy
• B. Increased pulse rate and blood pressure
• C. Muscle weakness
• D. Muscle irritability

Correct answer: C

Rationale: Muscle weakness is a hallmark symptom of hypokalemia. Hypokalemia refers to low levels of potassium in the blood, which can affect muscle function. The decreased potassium levels can lead to muscle weakness, cramping, and even paralysis. These symptoms can impact various muscle groups in the body, making muscle weakness the most significant symptom to monitor and address in patients with hypokalemia.

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