Nursing Elites

1. 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.

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. A 54-year-old male client and his wife were informed this morning that he has terminal cancer. Which nursing intervention is likely to be most beneficial?

• A. Ask the wife how she would like to participate in the client's care
• B. Provide the wife with information about hospice
• C. Encourage the wife to visit after painful treatments are completed
• D. Refer the wife to a support group for family members of those dying of cancer

Correct answer: A

Rationale: The most beneficial nursing intervention in this situation is to ask the wife how she would like to participate in the client's care. Involving the spouse in the care of the terminally ill client can provide comfort, support, and a sense of contribution during a challenging time. Providing information about hospice (B) is important but may not be the immediate priority. Encouraging the wife to visit after treatments are completed (C) may delay her involvement in the care. Referring her to a support group (D) is a good idea but might be more suitable at a later stage.

4. The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to the procedure?

• A. Experiences facial swelling after eating crab
• B. Reports left chest wall pain prior to the admission
• C. Verbalizes a fear of being in a confined space
• D. Drank a glass of water

Correct answer: A

Rationale: The correct answer is A. Allergy to shellfish can indicate a potential allergy to iodine, which is used in contrast dye for the procedure. This must be explored further to prevent an allergic reaction. Choice B is not directly related to the angioplasty procedure. Choice C pertains to claustrophobia, which can be addressed but is not directly related to the safety of the procedure. Choice D is a routine activity and does not pose a risk to the client during the procedure.

5. When assessing a male client, the nurse finds that he is fatigued, and is experiencing muscle weakness, leg cramps, and cardiac dysrhythmias. Based on these findings, the nurse plans to check the client's laboratory values to validate the existence of which?

• A. Hyperphosphatemia
• B. Hypocalcemia
• C. Hypermagnesemia
• D. Hypokalemia

Correct answer: D

Rationale: The correct answer is D, Hypokalemia. Generalized weakness, muscle weakness, leg cramps, and cardiac dysrhythmias are manifestations of hypokalemia. Checking the potassium level is essential in this case. Hypocalcemia typically presents with facial muscle spasms, not the symptoms mentioned. Hypermagnesemia does not typically cause the symptoms described. It's important to note that orange juice is high in potassium and would be advisable to drink if the patient was hypokalemic. Loose stools are more commonly associated with hyperkalemia, not hypokalemia.

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