Nursing Elites

1. 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.

2. A nurse is assessing a client who has hypothyroidism. Which of the following findings should the nurse expect?

• A. Bradycardia
• B. Weight gain
• C. Hypertension
• D. Decreased deep tendon reflexes

Correct answer: D

Rationale: Corrected Rationale: Decreased deep tendon reflexes are a common finding in clients with hypothyroidism due to slowed metabolic processes. The other choices, such as bradycardia (slow heart rate), weight gain, and hypertension (high blood pressure) are not typically associated with hypothyroidism. Bradycardia can occur due to the decreased metabolic rate, but it is not a consistent finding. Weight gain is common but not universal, and hypertension is more commonly associated with hyperthyroidism.

3. A nurse in a pediatric unit is preparing to insert an IV catheter for a 7-year-old. Which of the following actions should the nurse take?

• A. Allow the child to handle the IV supplies to become familiar with them.
• B. Tell the child they will feel discomfort during the catheter insertion.
• C. Use a mummy restraint to hold the child during the catheter insertion.
• D. Require the parents to leave the room during the procedure.

Correct answer: B

Rationale: The correct answer is B because informing the child that they will feel discomfort during catheter insertion is crucial to prepare them for the procedure. Choice A is incorrect as children should not handle medical supplies. Choice C is inappropriate as using a restraint can cause anxiety and fear in the child. Choice D is not necessary as having parents present can provide comfort and support to the child during the procedure.

4. A nurse is providing dietary teaching to a client who has chronic kidney disease. Which of the following food choices by the client indicates an understanding of the teaching?

• A. Peanut butter and jelly sandwich
• B. Grilled chicken and rice
• C. Tomato soup with saltine crackers
• D. Baked fish and steamed vegetables

Correct answer: D

Rationale: The correct answer is D, baked fish and steamed vegetables. These food choices are low in potassium and phosphorus, which is important for clients with chronic kidney disease to manage their condition effectively. Grilled chicken and rice (choice B) may be high in phosphorus, tomato soup with saltine crackers (choice C) is high in sodium, and a peanut butter and jelly sandwich (choice A) contains high levels of potassium, all of which are not ideal choices for individuals with chronic kidney disease.

5. A nurse is caring for a client who is receiving continuous enteral nutrition through a nasogastric tube. Which of the following actions should the nurse take?

• A. Administer the feeding using a large-bore syringe
• B. Check the placement of the tube every 8 hours
• C. Flush the tube with 5 mL of water every 6 hours
• D. Maintain the client in an upright position

Correct answer: B

Rationale: The correct action for the nurse to take is to check the placement of the nasogastric tube every 8 hours. This is crucial to ensure that the tube is correctly positioned in the stomach, reducing the risk of complications such as aspiration. Administering the feeding using a large-bore syringe (Choice A) is not recommended for enteral nutrition. Flushing the tube with water every 6 hours (Choice C) is not necessary for continuous enteral nutrition. Maintaining the client in an upright position (Choice D) is generally preferred to reduce the risk of aspiration, but it is not the most critical action compared to verifying tube placement.

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