Nursing Elites

1. A patient who has small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the healthcare provider about which assessment finding?

• A. Reported weight gain
• B. Serum hematocrit of 42%
• C. Serum sodium level of 120 mEq/L
• D. Total urinary output of 280 mL during the past 8 hours

Correct answer: C

Rationale: The correct answer is C, a serum sodium level of 120 mEq/L. Hyponatremia is the most important finding to report in SIADH. SIADH causes water retention and a decrease in serum sodium levels. Hyponatremia can lead to confusion and other central nervous system effects and requires treatment. Adequate kidney function is indicated by a urinary output of at least 30 mL/hr. A hematocrit level of 42% is normal. Weight gain is expected due to water retention in SIADH.

2. What is the first action the nurse should take when a patient complains of acute chest pain and dyspnea soon after insertion of a centrally inserted IV catheter?

• A. Notify the health care provider.
• B. Offer reassurance to the patient.
• C. Auscultate the patient’s breath sounds
• D. Give the prescribed PRN morphine sulfate IV

Correct answer: C

Rationale: The correct first action for the nurse to take when a patient complains of acute chest pain and dyspnea after the insertion of a centrally inserted IV catheter is to auscultate the patient's breath sounds. This is important to assess for any potential complications such as embolism or pneumothorax, which can present with such symptoms. Auscultation can provide immediate information on the patient's respiratory status and guide further interventions. Notifying the health care provider, offering reassurance, or administering morphine should only be considered after assessing the patient's condition through auscultation.

3. The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be a priority for the nurse to report to the health care provider?

• A. Oral temperature of 100.1°F
• B. Serum sodium level of 138 mEq/L (138 mmol/L)
• C. Gradually decreasing level of consciousness (LOC)
• D. Weight gain of 2 pounds (1 kg) above the admission weight

Correct answer: C

Rationale: The priority assessment finding for the nurse to report to the healthcare provider is a gradually decreasing level of consciousness (LOC). This change in LOC could indicate fluid and electrolyte disturbances, which require immediate attention to prevent complications. While the other options such as an elevated temperature, serum sodium level, and weight gain are important to note and report, they do not indicate an urgent need for intervention compared to changes in LOC which could signify serious issues that need prompt evaluation and management.

4. IV potassium chloride (KCl) 60 mEq is prescribed for the treatment of a patient with severe hypokalemia. Which action should the nurse take?

• A. Administer the KCl as a rapid IV bolus.
• B. Infuse the KCl at a rate of 10 mEq/hour.
• C. Only give the KCl through a central venous line.
• D. Discontinue cardiac monitoring during the infusion.

Correct answer: B

Rationale: The correct action for the nurse to take is to infuse the KCl at a rate of 10 mEq/hour. Rapid IV infusion of KCl can lead to cardiac arrest due to its potential for causing hyperkalemia. While KCl can be administered through peripheral veins, central venous lines are not necessary unless specified. It is crucial to continue cardiac monitoring during potassium infusion to promptly identify and manage any potential dysrhythmias that may occur.

5. A client with bladder cancer had surgical placement of a ureteroileostomy (ileal conduit) yesterday. Which postoperative assessment finding should the nurse report to the healthcare provider immediately?

• A. red and edematous stoma appearance
• B. liquid brown drainage from stoma
• C. stoma output of 40ml in the last hour
• D. mucous strings floating in the drainage

Correct answer: C

Rationale: Stoma output of only 40ml in the last hour may indicate a problem, such as dehydration or blockage, and should be reported immediately. A red and edematous stoma appearance could be due to inflammation, which is expected in the early postoperative period. Liquid brown drainage from the stoma is a normal finding. Mucous strings floating in the drainage are also a common occurrence postoperatively and do not typically require immediate reporting.

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