Nursing Elites

1. A nurse in the outpatient clinic is caring for a patient who has a magnesium level of 1.3 mg/dL. Which assessment would be most important for the nurse to make?

• A. Daily alcohol intake
• B. Intake of dietary protein
• C. Multivitamin/mineral use
• D. Use of over-the-counter (OTC) laxatives

Correct answer: A

Rationale: The correct answer is A: Daily alcohol intake. Hypomagnesemia is often associated with alcoholism, making it crucial for the nurse to assess the patient's alcohol consumption. Protein intake is not directly related to magnesium levels. The use of over-the-counter laxatives and multivitamin/mineral supplements would typically increase magnesium levels, which are not the focus when dealing with hypomagnesemia.

2. A patient comes to the clinic complaining of frequent, watery stools for the last 2 days. Which action should the nurse take first?

• A. Obtain the baseline weight
• B. Check the patient’s blood pressure
• C. Draw blood for serum electrolyte levels
• D. Ask about any extremity numbness or tingling

Correct answer: B

Rationale: The correct answer is to check the patient’s blood pressure. Given the patient's symptoms of frequent, watery stools, there is a concern for fluid volume deficit. Assessing the blood pressure helps determine the patient's perfusion status, which is crucial in managing fluid volume deficits. While obtaining baseline weight, drawing blood for serum electrolyte levels, and asking about extremity numbness or tingling are important assessments, checking the blood pressure takes precedence as it provides immediate information on the patient's circulatory status.

3. A male client with unstable angina needs a cardiac catheterization. So the healthcare provider explains the risks and benefits of the procedure and then leaves to set up for the procedure. When the nurse presents the consent form for signature, the client hesitates and asks how the wires will keep his heart going. Which action should the nurse take?

• A. Answer the client's specific questions with a short, understandable explanation
• B. Postpone the procedure until the client understands the risks and benefits
• C. Call the client's next of kin and ask them to provide verbal consent
• D. Page the healthcare provider to return and provide additional explanation

Correct answer: D

Rationale: The correct action for the nurse to take in this situation is to page the healthcare provider to return and provide additional explanation. It is crucial for the client to have a clear understanding of the procedure, including its risks and benefits, before signing the consent form. While the nurse can provide general information, the detailed explanation of how the procedure works and its effects should come from the healthcare provider who will perform the procedure. Postponing the procedure until the client understands is appropriate, but the immediate need is to clarify the client's concerns with the healthcare provider. Calling the client's next of kin for verbal consent is not the correct course of action as the client is present and able to provide consent after receiving adequate information.

4. At 01:00 on a male client's second postoperative night, the client states he is unable to sleep and plans to read until feeling sleepy. What action should the nurse implement?

• A. Leave the room and close the door to the client's room
• B. Assess the appearance of the client's surgical dressing
• C. Bring the client a prescribed PRN sedative-hypnotic
• D. Discuss symptoms of sleep deprivation with the client

Correct answer: A

Rationale: The client has a plan to read until feeling sleepy, indicating an intention to sleep. Therefore, offering a PRN sedative-hypnotic (C) is unnecessary, especially since it is a stronger sleep aid. Option (D) is not needed as the client already has a plan to address his sleeplessness. Assessing the surgical dressing (B) is not relevant to the client's immediate need for sleep. Leaving the room and closing the door (A) is the appropriate action to provide a conducive environment for the client to rest.

5. The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to the procedure?

• A. Experiences facial swelling after eating crab
• B. Reports left chest wall pain prior to the admission
• C. Verbalizes a fear of being in a confined space
• D. Drank a glass of water

Correct answer: A

Rationale: The correct answer is A. Allergy to shellfish can indicate a potential allergy to iodine, which is used in contrast dye for the procedure. This must be explored further to prevent an allergic reaction. Choice B is not directly related to the angioplasty procedure. Choice C pertains to claustrophobia, which can be addressed but is not directly related to the safety of the procedure. Choice D is a routine activity and does not pose a risk to the client during the procedure.

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