Nursing Elites

1. A nurse is reviewing the medical record of a client who has a new prescription for potassium chloride. Which of the following findings should the nurse report to the provider?

• A. Blood pressure 110/70 mm Hg
• B. Heart rate 88/min
• C. Serum potassium 3.2 mEq/L
• D. Sodium 136 mEq/L

Correct answer: C

Rationale: The correct answer is C. A serum potassium level of 3.2 mEq/L is below the normal range, indicating hypokalemia. Before administering potassium chloride, which is used to treat low potassium levels, the nurse should report this finding to the provider for further evaluation and potential adjustment of the treatment plan. Choices A, B, and D are within normal ranges and do not directly relate to the need for potassium chloride administration.

2. A nurse is providing teaching to a client who is receiving radiation therapy for cancer of the larynx. Which of the following instructions should the nurse include?

• A. Apply heat to the neck to relieve pain.
• B. Use a soft-bristle toothbrush to prevent gum irritation.
• C. Rinse your mouth with an alcohol-free mouthwash twice daily.
• D. Wear loose-fitting clothing to protect your skin.

Correct answer: B

Rationale: The correct answer is to use a soft-bristle toothbrush to prevent gum irritation in clients undergoing radiation therapy for laryngeal cancer. Radiation therapy can cause oral mucositis and increase the risk of gum irritation, so using a soft-bristle toothbrush is recommended to minimize trauma to the gums and oral mucosa. Applying heat to the neck is contraindicated as it can exacerbate tissue damage caused by radiation. Rinsing the mouth with an alcohol-free mouthwash is preferred over an alcohol-based one to prevent drying and irritation of the oral mucosa. Wearing loose-fitting clothing is advised to prevent friction and irritation on the skin, rather than tight-fitting clothing that may cause pressure ulcers or skin breakdown.

3. A client with cancer is about to receive low-dose brachytherapy via a vaginal implant. What intervention should be included in the care plan?

• A. Remove vaginal packing.
• B. Insert an indwelling urinary catheter.
• C. Ambulate the client four times daily.
• D. Keep the client NPO until therapy is complete.

Correct answer: B

Rationale: The correct intervention that should be included in the care plan for a client about to receive low-dose brachytherapy via a vaginal implant is to insert an indwelling urinary catheter. This is crucial to prevent bladder distention during brachytherapy, ensuring the treatment's effectiveness and the client's comfort. Removing vaginal packing (Choice A) may not be necessary or appropriate in this situation. Ambulating the client four times daily (Choice C) is a good nursing intervention for general patient care but is not specifically related to brachytherapy via a vaginal implant. Keeping the client NPO until therapy is complete (Choice D) is not necessary unless specifically indicated due to the treatment's nature or the client's condition.

4. Which laboratory test is essential for monitoring renal function in a patient with chronic kidney disease?

• A. Monitor BUN and creatinine levels
• B. Check blood glucose levels
• C. Monitor hemoglobin and hematocrit levels
• D. Monitor liver enzymes

Correct answer: A

Rationale: The correct answer is to monitor BUN (Blood Urea Nitrogen) and creatinine levels in a patient with chronic kidney disease. These tests provide crucial information about renal function. Checking blood glucose levels (Choice B) is important for monitoring diabetes, not renal function. Monitoring hemoglobin and hematocrit levels (Choice C) helps assess anemia, not specifically renal function. Monitoring liver enzymes (Choice D) is relevant for assessing liver function, not renal function.

5. A nurse is teaching a client who has a new prescription for iron supplements. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should take this medication with a glass of milk.
• B. I will take this medication with orange juice.
• C. I should expect my stools to be black and tarry.
• D. I will take this medication before bedtime.

Correct answer: C

Rationale: The correct answer is C. When a client understands the teaching about iron supplements, they should know that black, tarry stools are a normal side effect. This indicates that the medication is being absorbed and working effectively. Choices A and B are incorrect because iron supplements should not be taken with milk or orange juice, as these can interfere with the absorption of iron. Choice D is also incorrect because iron supplements are usually best absorbed on an empty stomach, so taking them before bedtime may not be ideal.

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