Nursing Elites

1. A nurse is reviewing the laboratory report of a client who has been receiving lithium carbonate for the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the following orders from the provider should the nurse expect?

• A. Withhold the next dose.
• B. Increase the dosage.
• C. Discontinue the medication.
• D. Administer the medication.

Correct answer: D

Rationale: Administering the medication is appropriate for a stable lithium level of 0.8 mEq/L. A level of 0.8 mEq/L falls within the therapeutic range for lithium, indicating that the client is receiving an adequate dose to maintain therapeutic effects. Withholding the next dose, increasing the dosage, or discontinuing the medication would not be indicated at this lithium level as it is within the desired range for therapeutic benefit. Therefore, the correct action would be to continue administering the medication to ensure the client maintains the therapeutic level of lithium.

2. When teaching a client about nutritional intake, what should be included?

• A. Carbohydrates should be at least 45% of your caloric intake.
• B. Protein should be at least 55% of your caloric intake.
• C. Carbohydrates should be at least 30% of your caloric intake.
• D. Protein should be at least 60% of your caloric intake.

Correct answer: A

Rationale: When educating a client about nutritional intake, it is important to mention that carbohydrates should constitute at least 45% of their daily caloric intake for a balanced diet. This macronutrient provides energy and is essential for proper bodily functions. Choice B is incorrect because protein should typically account for around 10-35% of total caloric intake, not 55%. Choice C is too low for the recommended carbohydrate intake, as it should be higher at 45%. Choice D is incorrect as protein intake should generally be around 10-35% of total caloric intake, not 60%.

3. A client receiving a blood transfusion develops a fever. What action should the nurse take?

• A. Stop the transfusion immediately.
• B. Administer an antihistamine as prescribed.
• C. Administer a diuretic as prescribed.
• D. Increase the transfusion rate.

Correct answer: A

Rationale: When a client receiving a blood transfusion develops a fever, the priority action for the nurse is to stop the transfusion immediately. A fever during a blood transfusion may indicate a transfusion reaction, and stopping the transfusion is crucial to prevent further complications. Administering an antihistamine (choice B) or a diuretic (choice C) without assessing and addressing the potential transfusion reaction can be harmful. Increasing the transfusion rate (choice D) is contraindicated as it can exacerbate any adverse reactions the client is experiencing.

4. A nurse is preparing to administer a rectal suppository to a client. What action should the nurse take?

• A. Encourage the client to hold their breath as long as possible.
• B. Insert the suppository just past the anal sphincter.
• C. Lubricate the suppository and insert it 1.5 cm (0.6 in) into the rectum.
• D. Place the client in a Sims' position before inserting the suppository.

Correct answer: D

Rationale: The correct action the nurse should take when administering a rectal suppository is to place the client in a Sims' position. This position helps facilitate the proper administration of the suppository by allowing better access to the rectum. Encouraging the client to hold their breath as long as possible (Choice A) is unnecessary and not related to the administration of a rectal suppository. Inserting the suppository just past the anal sphincter (Choice B) is incorrect as it may not reach the rectum where it needs to be placed. Lubricating the suppository and inserting it 1.5 cm into the rectum (Choice C) is incorrect as the suppository needs to be inserted deeper into the rectum for proper absorption.

5. A client is 2 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?

• A. Position the client supine with a pillow between the legs.
• B. Place an abduction pillow between the client's legs.
• C. Place a pillow under the client's knees.
• D. Position the client's legs in adduction.

Correct answer: B

Rationale: After a total hip arthroplasty, it is crucial to prevent hip dislocation. Placing an abduction pillow between the client's legs helps maintain proper alignment of the hip joint and prevents adduction, which could lead to dislocation. Therefore, choice B is the correct action. Choice A is incorrect because positioning the client supine with a pillow between the legs does not provide the necessary abduction to prevent dislocation. Choice C, placing a pillow under the client's knees, does not address the need for abduction. Choice D, positioning the client's legs in adduction, is incorrect as adduction increases the risk of hip dislocation following hip arthroplasty.

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