Nursing Elites

1. A nurse is assessing a client for signs of hypokalemia. Which of the following findings should the nurse look for?

• A. Muscle weakness
• B. Weight gain
• C. Elevated blood pressure
• D. Increased thirst

Correct answer: A

Rationale: Muscle weakness is a classic sign of hypokalemia. Potassium plays a crucial role in muscle function, and low potassium levels can lead to muscle weakness. Weight gain, elevated blood pressure, and increased thirst are not typically associated with hypokalemia. Weight gain can be seen in conditions like fluid retention, elevated blood pressure can result from various causes, and increased thirst may be a symptom of conditions like diabetes.

2. A nurse is sitting with the partner of a client who recently died. Which action should the nurse take to facilitate mourning?

• A. Offer advice on coping strategies
• B. Encourage the partner to ask for help when needed
• C. Discuss the importance of grieving alone
• D. Suggest the partner avoid talking about the loss

Correct answer: B

Rationale: Encouraging the partner to ask for help when needed is the most appropriate action for the nurse to facilitate mourning. Grieving is a challenging process, and individuals may require support from others to cope effectively. Offering advice on coping strategies, discussing the importance of grieving alone, or suggesting avoiding talking about the loss could hinder the partner's mourning process by isolating them or suppressing their feelings.

3. When teaching a client about the use of lisinopril, which of the following should be included?

• A. It can cause a persistent cough
• B. It is a calcium channel blocker
• C. It is safe during pregnancy
• D. It should be taken with food

Correct answer: A

Rationale: The correct answer is A. Lisinopril is an ACE inhibitor, and a common side effect associated with its use is a persistent cough. This is important information that the client should be aware of. Choice B is incorrect because lisinopril is not a calcium channel blocker, it is an ACE inhibitor. Choice C is incorrect as lisinopril is not considered safe during pregnancy, especially during the second and third trimesters as it can cause harm to the fetus. Choice D is incorrect because lisinopril is typically recommended to be taken on an empty stomach, about an hour before meals.

4. When providing education on the use of insulin, what should be included?

• A. Insulin can be stored at room temperature indefinitely
• B. Monitor blood glucose levels before administration
• C. Insulin is a long-acting medication
• D. Insulin has no side effects

Correct answer: B

Rationale: The correct answer is to monitor blood glucose levels before administration. This step is crucial to ensure the correct dose of insulin is administered based on the current blood glucose level. Choice A is incorrect as insulin usually needs to be stored in the refrigerator and has an expiration date. Choice C is incorrect because insulin can be short-acting, rapid-acting, intermediate-acting, or long-acting. Choice D is also incorrect as insulin can have side effects such as hypoglycemia if the dose is too high.

5. A nurse receives a report on four clients. Which client should the nurse assess first?

• A. A client scheduled for chemotherapy with a hemoglobin of 9 g/dL
• B. A client 24 hours post-TURP with small blood clots in the catheter
• C. A client receiving a blood transfusion who reports low back pain
• D. A client with a new colostomy and a reddish-pink stoma

Correct answer: C

Rationale: The correct answer is C. Low back pain during a blood transfusion is a classic sign of a transfusion reaction, specifically a transfusion-associated circulatory overload (TACO) or hemolytic reaction, both of which require immediate attention to prevent serious complications. Assessing this client first is crucial to ensure prompt intervention. Choices A, B, and D do not indicate immediate life-threatening complications and can be addressed after the client experiencing low back pain during a blood transfusion is stabilized.

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