Nursing Elites

1. A patient with renal failure has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. The patient arrives for outpatient hemodialysis and is unresponsive to questions and has decreased deep tendon reflexes. Which action should the dialysis nurse take first?

• A. Notify the patient’s health care provider.
• B. Obtain an order to draw a potassium level.
• C. Review the magnesium level on the patient’s chart.
• D. Teach the patient about the risk of magnesium-containing antacids

Correct answer: A

Rationale: The health care provider should be notified immediately. The patient has a history and manifestations consistent with hypermagnesemia. The nurse should check the chart for a recent serum magnesium level and make sure that blood is sent to the laboratory for immediate electrolyte and chemistry determinations. Dialysis should correct the high magnesium levels. The patient needs teaching about the risks of taking magnesium-containing antacids. Monitoring of potassium levels also is important for patients with renal failure, but the patient’s current symptoms are not consistent with hyperkalemia.

2. Following a thyroidectomy, a patient complains of “a tingling feeling around my mouth.” Which assessment should the nurse complete immediately?

• A. Presence of the Chvostek’s sign
• B. Abnormal serum potassium level
• C. Decreased thyroid hormone level
• D. Bleeding on the patient’s dressing

Correct answer: A

Rationale: The correct assessment the nurse should complete immediately is checking for the presence of the Chvostek’s sign. The patient's complaint of tingling around the mouth is indicative of hypocalcemia, which can result from parathyroid injury/removal during thyroidectomy. The Chvostek’s sign is a clinical indication of hypocalcemia, where facial muscle twitching occurs when the facial nerve is tapped. Assessing serum potassium levels (choice B) is not the priority in this situation. While thyroid hormone levels (choice C) play a role in overall health, they do not directly relate to the patient’s current symptoms. Checking for bleeding on the dressing (choice D) is important but not the immediate priority when addressing potential hypocalcemia.

3. A postoperative client has three different PRN analgesics prescribed for different levels of pain. The nurse inadvertently administers a dose that is not within the prescribed parameters. What actions should the nurse take first?

• A. Assess for side effects of the medication.
• B. Document the client's responses.
• C. Complete a medication error report.
• D. Determine if the pain was relieved.

Correct answer: A

Rationale: This is a medication error, and the first step in addressing it is to assess for any side effects of the medication on the patient. Some analgesics can cause respiratory depression, so it is crucial to monitor for vital sign changes or respiratory distress. Once the patient is stable, the next steps would include contacting the provider, documenting the response, and completing a medication error report. Choices B, C, and D are not the immediate priority when dealing with a medication error. While documenting the client's responses and completing a medication error report are important, assessing for side effects and ensuring patient safety come first.

4. When assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate, which finding should the nurse report to the health care provider immediately?

• A. The bibasilar breath sounds are decreased.
• B. The patellar and triceps reflexes are absent.
• C. The patient has been sleeping most of the day.
• D. The patient reports feeling 'sick to my stomach.'

Correct answer: B

Rationale: The correct answer is B because the absence of patellar and triceps reflexes indicates potential magnesium toxicity, requiring immediate intervention. Nausea and lethargy are common side effects of elevated magnesium levels and should be reported, but they are not as critical as the loss of deep tendon reflexes. Decreased breath sounds suggest the need for coughing and deep breathing to prevent atelectasis, which is important but not as urgent as addressing magnesium toxicity.

5. A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor while the patient is receiving this infusion?

• A. Lung sounds
• B. Urinary output
• C. Peripheral pulses
• D. Peripheral edema

Correct answer: A

Rationale: The correct answer is A: Lung sounds. Hypertonic solutions like 3% NaCl can cause water retention, leading to fluid excess. Monitoring lung sounds is crucial as crackles may indicate pulmonary edema, a serious manifestation of fluid excess. While monitoring urinary output, peripheral pulses, and peripheral edema are also important when administering hypertonic solutions, they do not provide immediate clues to acute respiratory or cardiac decompensation like lung sounds.

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