Nursing Elites

1. When a patient refuses to remove their religious jewelry before surgery, what is the best response for the nurse preparing for the procedure?

• A. Proceed with the surgery and document the refusal.
• B. Ask the patient for permission to secure the jewelry safely.
• C. Tape the jewelry to the patient's body during surgery.
• D. Tell the patient they must remove the jewelry for safety reasons.

Correct answer: B

Rationale: The best response for the nurse is to ask the patient for permission to secure the jewelry safely. Hospital policy typically requires jewelry to be secured or removed to prevent interference during surgery. Proceeding with the surgery without addressing the issue or taping the jewelry to the patient's body are not safe practices and can lead to complications during the procedure. Directing the patient to remove the jewelry without exploring alternative solutions is not patient-centered care and may create unnecessary tension.

2. A healthcare provider is reviewing a client's lab results. Which of the following lab values should the provider report?

• A. Magnesium 1.9 mEq/L
• B. Potassium 3.6 mEq/L
• C. Sodium 126 mEq/L
• D. Chloride 99 mEq/L

Correct answer: C

Rationale: The correct answer is C: Sodium 126 mEq/L. A sodium level of 126 mEq/L is below the normal range, indicating hyponatremia, which can have serious health implications and should be reported to the healthcare provider for further evaluation and intervention. Choices A, B, and D are within or close to the normal ranges for magnesium, potassium, and chloride, respectively, and do not require immediate reporting as they are not significantly abnormal.

3. A healthcare provider is caring for a client who has heart failure and is prescribed enalapril. The provider should monitor the client for which of the following adverse effects?

• A. Hypertension
• B. Hypokalemia
• C. Hyperglycemia
• D. Hyperkalemia

Correct answer: D

Rationale: Corrected Question: When a client with heart failure is prescribed enalapril, monitoring for hyperkalemia is essential. Enalapril is an angiotensin-converting enzyme (ACE) inhibitor that can lead to an increase in potassium levels in the blood. This adverse effect can be serious and potentially life-threatening. Choices A, B, and C are incorrect because enalapril does not typically cause hypertension, hypokalemia, or hyperglycemia as adverse effects. It's essential for healthcare providers to be vigilant in monitoring potassium levels when clients are on ACE inhibitors like enalapril.

4. A client is preparing for a surgical procedure but refuses to remove religious jewelry. What is the best course of action?

• A. Proceed with surgery and document the refusal.
• B. Ask the client for permission to secure the jewelry.
• C. Remove the jewelry and store it safely.
• D. Postpone the surgery until the jewelry is removed.

Correct answer: B

Rationale: The best course of action is to ask the client for permission to secure the jewelry. This respects the client's religious beliefs while also ensuring that the jewelry does not interfere during the surgical procedure. Proceeding with surgery without addressing the presence of the jewelry can lead to complications or distress for the client. Removing the jewelry without consent or postponing the surgery solely due to the presence of religious jewelry are not appropriate actions in this situation.

5. How is the effectiveness of a diuretic in a patient with heart failure evaluated?

• A. Checking daily weights and lung sounds for improvement
• B. Assessing the patient's blood pressure and urine output
• C. Monitoring for weight loss and reduction in edema
• D. Measuring the patient's heart rate and lung sounds

Correct answer: A

Rationale: The correct way to evaluate the effectiveness of a diuretic in a patient with heart failure is by checking daily weights and lung sounds for improvement. Daily weights help to assess fluid retention changes, while improvement in lung sounds indicates reduced pulmonary congestion. Assessing blood pressure and urine output (Choice B) is important but does not directly evaluate the effectiveness of the diuretic. Monitoring for weight loss and reduction in edema (Choice C) are valid indicators of diuretic effectiveness, but direct observation of daily weights and lung sounds is more specific. Measuring heart rate and lung sounds (Choice D) is relevant but does not directly assess the impact of the diuretic on fluid balance and pulmonary status.

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