Nursing Elites

1. A client with newly diagnosed hypertension is being taught about lifestyle modifications by a nurse. Which client statement indicates a need for further teaching?

• A. ‘I will reduce my salt intake to help manage my blood pressure.’
• B. ‘I will start exercising regularly to help control my blood pressure.’
• C. ‘I will avoid drinking alcohol to help manage my blood pressure.’
• D. ‘I will limit my caffeine intake to help control my blood pressure.’

Correct answer: D

Rationale: The correct answer is D. Limiting caffeine intake is a positive lifestyle modification for managing hypertension. The statement indicates that the client understands the importance of reducing caffeine intake. Choices A, B, and C all reflect appropriate lifestyle modifications for managing hypertension, indicating good understanding by the client.

2. The nurse is assessing a client with chronic heart failure who is receiving furosemide (Lasix). Which assessment finding is most concerning?

• A. Heart rate of 60 beats per minute
• B. Blood pressure of 110/70 mmHg
• C. Elevated liver enzymes
• D. Elevated blood glucose level

Correct answer: C

Rationale: Elevated liver enzymes are most concerning in a client with chronic heart failure as they may indicate liver congestion or worsening heart failure, requiring immediate intervention. Elevated liver enzymes can be a sign of hepatotoxicity or liver damage, which could be a result of furosemide (Lasix) use. Monitoring liver function is crucial in patients taking furosemide due to the risk of hepatotoxicity. A heart rate of 60 beats per minute and a blood pressure of 110/70 mmHg are within normal ranges for a client with chronic heart failure. An elevated blood glucose level may be expected due to the effects of furosemide but is not as immediately concerning as elevated liver enzymes.

3. A client with chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation. Which laboratory value is most concerning?

• A. Serum potassium of 6.5 mEq/L
• B. Serum bicarbonate of 18 mEq/L
• C. Serum glucose of 350 mg/dl
• D. Serum sodium of 135 mEq/L

Correct answer: A

Rationale: A serum potassium level of 6.5 mEq/L is concerning in a client with COPD exacerbation as it may lead to life-threatening arrhythmias, requiring immediate intervention. Hyperkalemia can cause cardiac arrhythmias, which pose a significant risk to the patient's life. Options B, C, and D are not typically associated with immediate life-threatening risks in the context of a COPD exacerbation.

4. The nurse is caring for a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which laboratory value requires immediate intervention?

• A. Serum potassium of 5.5 mEq/L
• B. Serum creatinine of 2.5 mg/dL
• C. Hemoglobin of 10 g/dL
• D. White blood cell count of 10,000/mm³

Correct answer: A

Rationale: A serum potassium level of 5.5 mEq/L is most concerning in a client receiving erythropoietin therapy as it indicates hyperkalemia, requiring immediate intervention. High potassium levels can lead to severe cardiac arrhythmias and must be addressed promptly. The other laboratory values, though abnormal, do not present immediate life-threatening risks as hyperkalemia does.

5. A client is admitted for cellulitis surrounding an insect bite on the lower right arm, and intravenous (IV) antibiotic therapy is prescribed. Which action should the nurse implement before performing venipuncture?

• A. Lower the right arm below the level of the heart.
• B. Elevate the right arm on a pillow.
• C. Apply a tourniquet above the insertion site.
• D. Apply a warm compress to the insertion site.

Correct answer: A

Rationale: Before performing venipuncture for IV therapy, the nurse should lower the right arm below the level of the heart. Lowering the arm helps dilate the veins, making it easier to locate and access a suitable vein for the procedure. Elevating the arm on a pillow, applying a tourniquet above the insertion site, or applying a warm compress to the insertion site are not appropriate actions before venipuncture as they can affect the venous blood flow and make the procedure more challenging.

Similar Questions