Nursing Elites

1. After receiving change-of-shift report, which patient should the nurse assess first?

• A. Patient with a serum potassium level of 5.0 mEq/L who is complaining of abdominal cramping
• B. Patient with a serum sodium level of 145 mEq/L who has a dry mouth and is asking for a glass of water
• C. Patient with a serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes
• D. Patient with a serum phosphorus level of 4.5 mg/dL who has multiple soft tissue calcium-phosphate precipitates

Correct answer: C

Rationale: The correct answer is patient C with a serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes. The low magnesium level and neuromuscular irritability suggest that the patient may be at risk for seizures, which are life-threatening. Assessing and addressing this patient's condition promptly is crucial to prevent complications. Patients A, B, and D have mild electrolyte disturbances or symptoms that require attention, but they are not at immediate risk for life-threatening complications like seizures, unlike patient C.

2. A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction and is complaining of anxiety and incisional pain. The patient’s respiratory rate is 32 breaths/minute and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first?

• A. Discontinue the nasogastric suction.
• B. Give the patient the PRN IV morphine sulfate 4 mg.
• C. Notify the health care provider about the ABG results.
• D. Teach the patient how to take slow, deep breaths when anxious.

Correct answer: B

Rationale: The patient’s respiratory alkalosis is caused by the increased respiratory rate associated with pain and anxiety. The nurse’s first action should be to medicate the patient for pain. Although the nasogastric suction may contribute to the alkalosis, it is not appropriate to discontinue the tube when the patient needs gastric suction. The health care provider may be notified about the ABGs but is likely to instruct the nurse to medicate for pain. The patient will not be able to take slow, deep breaths when experiencing pain.

3. The nurse requests a meal tray for a client who follows Mormon beliefs and who is on a clear liquid diet following abdominal surgery. Which menu items should the nurse request for this client? (Select all that apply)

• A. apple juice
• B. black coffee
• C. orange juice
• D. hot chocolate

Correct answer: A

Rationale: The correct answer is A: apple juice. Clear liquids like apple juice and orange juice are suitable for a client following a clear liquid diet and Mormon beliefs. Options B and D, black coffee and hot chocolate, contain caffeine, which may not align with the client's religious dietary restrictions. Therefore, these options should be avoided for this client.

4. 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.

5. A female client's significant other has been at her bedside providing reassurances and support for the past 3 days, as desired by the client. The client's estranged husband arrives and demands that the significant other not be allowed to visit or be given condition updates. Which intervention should the nurse implement?

• A. Obtain a court order to enforce visitation rights for the significant other
• B. Request a consultation with the ethics committee for resolution of the situation
• C. Suggest involving security to manage the conflict between the husband and the significant other
• D. Discuss with the client the importance of setting clear boundaries with both individuals

Correct answer: B

Rationale: In this situation, where there is a conflict between the client's significant other and estranged husband, the most appropriate intervention is to request a consultation with the ethics committee for resolution. This ensures that an impartial body can assess the situation, consider the rights and preferences of all parties involved, and provide guidance on how to proceed in a fair and ethical manner. Obtaining a court order (Choice A) may be a legal option but should be considered after exhausting other conflict resolution methods. Involving security (Choice C) may escalate the situation and should only be considered if there is a risk of harm. Discussing boundaries with the client (Choice D) is important but may not immediately address the current conflict between the significant other and the husband.

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