Nursing Elites

1. A nurse is reviewing the laboratory results of a client who has hypokalemia. Which of the following findings should the nurse expect?

• A. Serum potassium 5.4 mEq/L
• B. Flat T waves
• C. Elevated ST segments
• D. Bradycardia

Correct answer: B

Rationale: Flat T waves are a characteristic ECG finding in hypokalemia. Hypokalemia causes a decrease in serum potassium levels, leading to altered cardiac conduction. Flat T waves are associated with hypokalemia-induced cardiac dysrhythmias. Elevated ST segments are typically seen in conditions like myocardial infarction, not in hypokalemia. Bradycardia is not a typical manifestation of hypokalemia; instead, tachycardia may occur due to potassium imbalances affecting the heart's electrical activity.

2. Which lab value is essential for a patient receiving warfarin therapy?

• A. Monitor INR
• B. Monitor sodium levels
• C. Monitor potassium levels
• D. Monitor platelet count

Correct answer: A

Rationale: The correct answer is to monitor the INR (International Normalized Ratio) for a patient receiving warfarin therapy. INR monitoring is crucial to assess the effectiveness of warfarin in preventing blood clots while minimizing the risk of bleeding. Monitoring sodium levels (choice B), potassium levels (choice C), or platelet count (choice D) is not specifically essential for patients on warfarin therapy and does not provide direct information on the drug's anticoagulant effects.

3. A nurse is preparing to insert an IV catheter for a client. Which of the following actions should the nurse take?

• A. Apply a tourniquet above the insertion site
• B. Shave the area around the insertion site
• C. Insert the catheter at a 15-degree angle
• D. Use an 18-gauge needle for insertion

Correct answer: C

Rationale: The correct answer is to insert the catheter at a 15-degree angle. This angle allows for easier venous access by ensuring proper catheter placement into the vein. Applying a tourniquet above the insertion site can help distend the vein for better visualization but is not the immediate action required for the insertion process. Shaving the area around the insertion site is not necessary unless there is excessive hair that may interfere with the insertion. Using an 18-gauge needle for insertion is a specific detail related to the equipment rather than the technique of insertion.

4. A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the following laboratory values should the nurse monitor to evaluate the effectiveness of the therapy?

• A. Serum potassium
• B. Platelets
• C. aPTT
• D. INR

Correct answer: C

Rationale: The correct answer is C: aPTT. Monitoring the activated partial thromboplastin time (aPTT) is crucial when a client is receiving heparin therapy. The aPTT reflects the clotting time and helps assess the effectiveness of heparin in preventing clot formation. Keeping the aPTT within the therapeutic range ensures that the medication is working optimally. Choices A, B, and D are incorrect because serum potassium, platelets, and INR are not direct indicators of heparin's effectiveness or therapeutic range.

5. A client with gastroesophageal reflux disease (GERD) is receiving teaching from a nurse. Which of the following instructions should the nurse include?

• A. Lie down after meals to reduce discomfort.
• B. Limit fluid intake to 1 liter per day.
• C. Avoid eating spicy foods.
• D. Eat three large meals each day.

Correct answer: C

Rationale: The correct answer is C: 'Avoid eating spicy foods.' Spicy foods can exacerbate symptoms of GERD by irritating the esophagus and causing discomfort. It is important for clients with GERD to avoid spicy foods to help manage their condition. Choices A, B, and D are incorrect. A client with GERD should not lie down after meals as this can worsen symptoms, limiting fluid intake to only 1 liter per day may not be appropriate for everyone, and eating three large meals each day can put pressure on the stomach and worsen GERD symptoms.

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