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 caring for a client receiving corticosteroids. Which of the following should the nurse monitor?

• A. Blood glucose levels
• B. Blood pressure
• C. Serum potassium levels
• D. Both A and B

Correct answer: D

Rationale: When a client is receiving corticosteroids, the nurse should monitor both blood glucose levels and blood pressure. Corticosteroids can elevate blood glucose levels, leading to hyperglycemia, and may cause hypertension. Monitoring these parameters is essential to detect and address any potential adverse effects promptly. While monitoring serum potassium levels is important in some situations, it is not a primary concern when caring for a client receiving corticosteroids. Therefore, choices A and B are the most appropriate options for monitoring in this scenario, making option D the correct answer.

3. A nurse on a pediatric care unit is delegating client care. Which of the following tasks should the nurse delegate to an assistive personnel?

• A. Initiate a dietary consult for a toddler
• B. Administer a glycerin suppository to a preschool-age child
• C. Evaluate gastric residual following intermittent feeding of an adolescent
• D. Transport a school-age child to x-ray

Correct answer: D

Rationale: The correct answer is D because transporting a stable child to x-ray is a task that can be safely delegated to an assistive personnel. This task does not require clinical judgment or specialized skills. Choices A, B, and C involve assessments and interventions that require nursing judgment and should be performed by a qualified nurse. Initiating a dietary consult for a toddler involves assessing the child's nutritional needs and must be done by a nurse. Administering a glycerin suppository to a preschool-age child requires medication administration skills and knowledge of appropriate dosages, which are within the nurse's scope of practice. Evaluating gastric residual following intermittent feeding of an adolescent is a clinical assessment that requires interpretation and decision-making based on the findings, making it a nursing responsibility.

4. A nurse is monitoring a client who has been receiving intermittent enteral feedings. What should the nurse identify as an intolerance to the feeding?

• A. Increased appetite
• B. Nausea
• C. Weight gain
• D. Regular bowel movements

Correct answer: B

Rationale: Nausea is a common sign of intolerance to enteral feedings. When a client experiences nausea, it can indicate difficulty in tolerating the feeding formula. This intolerance may also manifest as vomiting and dumping syndrome. Choices A, C, and D are incorrect because increased appetite, weight gain, and regular bowel movements are not typical signs of intolerance to enteral feedings.

5. A healthcare provider is assessing a client who has a heart rate of 40/min. The client is diaphoretic and has chest pain. Which of the following medications should the healthcare provider plan to administer?

• A. Lidocaine
• B. Adenosine
• C. Atropine
• D. Verapamil

Correct answer: C

Rationale: The client presents with bradycardia, diaphoresis, and chest pain, indicating reduced cardiac output. Atropine is the appropriate choice as it increases heart rate by blocking the parasympathetic nervous system. Lidocaine is used for ventricular arrhythmias, Adenosine for supraventricular tachycardia, and Verapamil for controlling heart rate in atrial fibrillation or atrial flutter. These medications are not suitable for the client's current presentation.

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