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 assessing a client who is receiving continuous enteral feedings through a nasogastric tube. Which of the following findings should the nurse report to the provider?

• A. Gastric residual of 200 mL
• B. Heart rate of 100/min
• C. Urinary output of 250 mL in 12 hr
• D. Blood glucose level of 180 mg/dL

Correct answer: D

Rationale: The correct answer is D. A blood glucose level of 180 mg/dL is higher than expected and should be reported to prevent hyperglycemia complications. High blood glucose levels can lead to hyperglycemia, causing various issues such as increased risk of infection and delayed wound healing. Choices A, B, and C are within normal limits for a client receiving continuous enteral feedings and do not require immediate reporting.

3. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following actions should the nurse take?

• A. Request a renewal of the prescription every 8 hours.
• B. Check the client's peripheral pulse rate every 30 minutes.
• C. Obtain a prescription for restraint within 4 hours.
• D. Document the client's condition every 15 minutes.

Correct answer: C

Rationale: When caring for a client with bipolar disorder experiencing acute mania and having obtained a verbal prescription for restraints, the nurse must ensure to obtain a formal written prescription for restraint within 4 hours. This is crucial to maintain the safety and proper care of the client. Choices A, B, and D are incorrect because renewing the prescription every 8 hours, checking pulse rate every 30 minutes, and documenting the client's condition every 15 minutes do not address the immediate need for a formal restraint prescription within 4 hours to manage the client's acute mania effectively.

4. 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.

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

• A. Potassium 4.0 mEq/L
• B. Calcium 9.5 mg/dL
• C. Magnesium 2.0 mEq/L
• D. Serum creatinine 3.0 mg/dL

Correct answer: D

Rationale: A serum creatinine level of 3.0 mg/dL indicates impaired kidney function, which is a concern when prescribing spironolactone as it can further affect renal function. Elevated serum creatinine levels may suggest decreased renal clearance of spironolactone, leading to potential toxicity. Potassium, calcium, and magnesium levels are within normal ranges and not directly related to spironolactone therapy. Therefore, the nurse should report the elevated serum creatinine level to the provider for further evaluation and possible dosage adjustment.

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