Nursing Elites

1. A nurse is reviewing a client's admission laboratory findings that indicate the client has hyponatremia. Which of the following laboratory findings should the nurse expect to be below the expected reference range?

• A. Magnesium
• B. Calcium
• C. Chloride
• D. Potassium

Correct answer: C

Rationale: The correct answer is C: Chloride. Chloride levels are typically low in cases of hyponatremia, as it often accompanies sodium loss. Magnesium (choice A) is not directly related to hyponatremia. Calcium (choice B) and Potassium (choice D) levels are usually not significantly affected by hyponatremia, making them less likely to be below the expected reference range in this scenario.

2. A client is lactose intolerant, and a nurse is reinforcing teaching. Which of the following statements should the nurse include?

• A. You should increase the fiber in your diet.
• B. You should increase the calories in your diet.
• C. You should decrease the dairy products in your diet.
• D. You should decrease the amount of vitamin D in your diet.

Correct answer: C

Rationale: The correct statement for a client who is lactose intolerant is to decrease dairy products since lactose intolerant individuals should avoid dairy to prevent symptoms like bloating, diarrhea, and gas. Increasing fiber (Choice A) or calories (Choice B) is not directly related to lactose intolerance. Decreasing vitamin D (Choice D) is not necessary as lactose intolerance is about the sugar in dairy, not vitamin D.

3. The nurse is discussing with a group of students the disease Kawasaki. What statement made by a student about Kawasaki disease is incorrect?

• A. It is also called mucocutaneous lymph node syndrome because it affects the mucous membranes (inside the mouth, throat, and nose), skin, and lymph nodes.
• B. In the second phase of the disease, findings include peeling of the skin on the hands and feet with joint and abdominal pain.
• C. Kawasaki disease occurs most often in boys, children younger than age 5, and children of Hispanic descent.
• D. Initially findings are a sudden high fever, usually above 104 degrees Fahrenheit, which lasts 1 to 2 weeks.

Correct answer: C

Rationale: The correct answer is C. Kawasaki disease occurs most often in boys and children younger than age 5, but there is no specific predisposition to children of Hispanic descent. Choice A is accurate, as Kawasaki disease does affect mucous membranes, skin, and lymph nodes. Choice B is correct, as peeling of the skin on the hands and feet with joint and abdominal pain are findings in the second phase of the disease. Choice D is accurate since initially, there is a sudden high fever that lasts 1 to 2 weeks.

4. A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time should be reported to the health care provider?

• A. Light pink urine
• B. Occasional suprapubic cramping
• C. Minimal drainage into the urinary collection bag
• D. Complaints of the feeling of pulling on the urinary catheter

Correct answer: C

Rationale: In a client with an indwelling catheter and continuous bladder irrigation post TURP, minimal drainage into the urinary collection bag should be reported to the health care provider. This finding could indicate a blockage in the catheter or a complication that requires immediate attention. Light pink urine (choice A) is expected due to bladder irrigation. Occasional suprapubic cramping (choice B) is common post-TURP. Complaints of the feeling of pulling on the urinary catheter (choice D) may indicate discomfort but do not suggest an urgent issue like a potential blockage.

5. After a client was taken off the ventilator following surgery, they have a nasogastric tube draining bile-colored liquids. Which nursing measure will provide the most comfort to the client?

• A. Allow the client to suck on ice chips
• B. Provide mints to freshen the breath
• C. Perform frequent oral care with a tooth sponge
• D. Swab the mouth with glycerin swabs

Correct answer: C

Rationale: Performing frequent oral care with a tooth sponge is the most appropriate nursing measure to provide comfort to a client with a nasogastric tube draining bile-colored liquids. This measure helps to maintain oral hygiene, prevent dryness, and enhance overall comfort. Allowing the client to suck on ice chips may not address oral hygiene needs, providing mints focuses more on breath freshness rather than comfort, and swabbing the mouth with glycerin swabs may not effectively address oral care needs.

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