Nursing Elites

1. A nurse is caring for a young adult at a college health clinic. Which of the following actions should the nurse take first?

• A. Give the client information about immunization against meningitis.
• B. Tell the client to have a TB skin test every 2 years.
• C. Determine the client’s health risks.
• D. Teach the client about exercise recommendations.

Correct answer: C

Rationale: Assessing the client’s health risks is the priority as it provides essential information to guide subsequent care. By understanding the client’s health risks, the nurse can tailor health education and interventions, such as immunizations and lifestyle modifications, to address specific needs. Providing information about immunization against meningitis (Choice A) is important but should come after assessing health risks. Instructing the client to have a TB skin test every 2 years (Choice B) is relevant but not the initial step in care. Teaching about exercise recommendations (Choice D) is also essential but should follow the assessment of health risks.

2. The healthcare professional is preparing to administer potassium chloride intravenously to a client with hypokalemia. Which action is most important?

• A. Monitor the client's respiratory rate
• B. Check the client's urine output
• C. Administer the potassium chloride as a rapid IV push
• D. Dilute the potassium chloride in an appropriate IV solution

Correct answer: D

Rationale: The correct answer is to dilute the potassium chloride in an appropriate IV solution. Potassium chloride should never be administered as a rapid IV push as it can lead to severe complications, including cardiac arrhythmias. Diluting the medication and administering it slowly helps reduce the risk of adverse effects. Monitoring the client's respiratory rate (Choice A) and checking urine output (Choice B) are important aspects of patient assessment but not the most crucial when administering potassium chloride. Administering potassium chloride as a rapid IV push (Choice C) is dangerous and can result in serious harm to the client.

3. The client is preparing for discharge following treatment for heart failure. Which statement by the client indicates a need for further teaching?

• A. I will weigh myself every day at the same time.
• B. I will call my doctor if my legs swell more.
• C. I will take my water pill only when I feel short of breath.
• D. I will limit the amount of salt in my diet.

Correct answer: C

Rationale: The correct answer is C. Taking water pills (diuretics) only when feeling short of breath is incorrect. Diuretics should be taken regularly as prescribed to manage fluid retention. Option A is correct as daily weight monitoring helps track for fluid retention. Option B is correct as worsening leg swelling should prompt contacting the healthcare provider. Option D is correct as limiting salt intake is essential in managing heart failure. Therefore, option C is the statement that indicates a need for further teaching.

4. A client with an NG tube is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first?

• A. Rinse the feeding bag with water between feedings
• B. Tell the client to keep the head of the bed elevated at least 30°
• C. Make sure the enteral formula is at room temperature
• D. Wipe the top of the formula can with alcohol

Correct answer: B

Rationale: The correct answer is to tell the client to keep the head of the bed elevated at least 30°. Elevating the head of the bed prevents aspiration of the enteral formula, which is a priority in caring for a client with an NG tube. This action helps in reducing the risk of complications such as pneumonia. Choices A, C, and D are incorrect. While rinsing the feeding bag, ensuring the enteral formula temperature, and maintaining cleanliness are important aspects of enteral feeding care, the priority is to prevent aspiration by keeping the head of the bed elevated. These actions can be implemented after ensuring the client's safety by maintaining the correct bed position.

5. A client with a terminal illness is being cared for by a nurse. Which of the following findings indicates that the client's death is imminent?

• A. Cold extremities
• B. Increased appetite
• C. Elevated blood pressure
• D. Increased level of consciousness

Correct answer: A

Rationale: Cold extremities are a common sign observed in clients nearing death. This occurs due to decreased blood circulation as the body's systems begin to shut down. Cold extremities indicate poor perfusion and reduced function of vital organs. Increased appetite (Choice B) is not typically seen in clients approaching death; instead, a decreased appetite is more common. Elevated blood pressure (Choice C) is not a typical finding in clients nearing the end of life, as blood pressure tends to decrease. An increased level of consciousness (Choice D) is also not indicative of imminent death, as clients near death often experience decreased level of consciousness or become unresponsive.

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