Nursing Elites

1. A patient comes to the clinic complaining of frequent, watery stools for the last 2 days. Which action should the nurse take first?

• A. Obtain the baseline weight
• B. Check the patient’s blood pressure
• C. Draw blood for serum electrolyte levels
• D. Ask about any extremity numbness or tingling

Correct answer: B

Rationale: The correct answer is to check the patient’s blood pressure. Given the patient's symptoms of frequent, watery stools, there is a concern for fluid volume deficit. Assessing the blood pressure helps determine the patient's perfusion status, which is crucial in managing fluid volume deficits. While obtaining baseline weight, drawing blood for serum electrolyte levels, and asking about extremity numbness or tingling are important assessments, checking the blood pressure takes precedence as it provides immediate information on the patient's circulatory status.

2. When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the patient’s food tray?

• A. Grape juice
• B. Milk carton
• C. Mixed green salad
• D. Fried chicken breast

Correct answer: B

Rationale: The correct answer is B: Milk carton. Foods high in phosphate, like milk and other dairy products, are restricted on low-phosphate diets to manage renal failure. Green, leafy vegetables, high-fat foods, and fruits/juices are not high in phosphate and are not restricted. Therefore, grape juice, mixed green salad, and fried chicken breast do not need to be removed from the patient's food tray.

3. The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum total protein level. Which assessment finding indicates that the patient’s condition has improved?

• A. Hematocrit 28%
• B. Absence of skin tenting
• C. Decreased peripheral edema
• D. Blood pressure 110/72 mm Hg

Correct answer: C

Rationale: The decrease in peripheral edema indicates an improvement in the patient’s protein status. Edema is caused by low oncotic pressure in individuals with low serum protein levels. Good skin turgor is an indicator of fluid balance, not protein status. A low hematocrit could be caused by poor protein intake. Blood pressure does not provide a useful clinical tool for monitoring protein status.

4. A patient who is taking a potassium-wasting diuretic for the treatment of hypertension complains of generalized weakness. It is most appropriate for the nurse to take which action?

• A. Assess for facial muscle spasms.
• B. Ask the patient about loose stools.
• C. Suggest that the patient avoid orange juice with meals.
• D. Ask the healthcare provider to order a basic metabolic panel.

Correct answer: D

Rationale: Generalized weakness is a sign of hypokalemia, a potential side effect of potassium-wasting diuretics. By requesting a basic metabolic panel, the nurse can assess the patient's potassium levels. Facial muscle spasms are associated with hypocalcemia, not hypokalemia. Advising the patient to avoid orange juice, which is high in potassium, would be counterproductive if the patient is hypokalemic. Loose stools are typically seen in hyperkalemia, not hypokalemia.

5. The nurse assesses a client who has a nasal cannula delivering oxygen at 2 L/min. To assess for skin damage related to the cannula, which areas should the nurse observe? (Select all that apply).

• A. Tops of the ears
• B. Bridge of the nose
• C. Around the nostrils
• D. Over the cheeks

Correct answer: C

Rationale: The correct answer is C: 'Around the nostrils.' Constant pressure from the tubing may create skin damage to the areas of skin and bony prominences the nasal cannula will be resting on, including around the nostrils. Choice A, 'Tops of the ears,' is incorrect as the cannula does not rest on the ears. Choice B, 'Bridge of the nose,' is incorrect because the cannula typically rests under the nose. Choice D, 'Over the cheeks,' is also incorrect as the cannula does not typically rest on the cheeks.

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