Nursing Elites

1. An older adult with chronic obstructive pulmonary disease (COPD) was recently admitted to the hospital with heart failure (HF). Which actions should the nurse take in providing care? (Select all that apply)

• A. Monitor electrolyte levels.
• B. Maintain pulse oximetry.
• C. Provide assistance with mobility.
• D. All of the Above

Correct answer: D

Rationale: In a patient with COPD and HF, monitoring electrolyte levels is essential due to potential imbalances caused by medications or fluid shifts. Maintaining pulse oximetry is crucial to assess oxygenation status in COPD and HF. Providing assistance with mobility helps prevent deconditioning and complications. Therefore, all the actions mentioned are necessary for comprehensive care in this scenario, making option D the correct answer. Choices A, B, and C are all important aspects of managing COPD and HF, ensuring holistic and effective care.

2. The cognitive impairment is classified into four levels based on the intelligence quotient (IQ). How is a child with an IQ of 45 classified?

• A. Within the normal low range
• B. Educable
• C. Trainable
• D. Severe

Correct answer: C

Rationale: A child with an IQ of 45 is classified as 'Trainable' in the context of cognitive impairment levels. This category is determined by an IQ range of 35 to 55. Choice A ('Within the normal low range') is incorrect as an IQ of 45 falls within the range associated with the 'Trainable' level, not the 'Normal low range.' Choice B ('Educable') is incorrect because this classification typically corresponds to individuals with slightly higher IQs that allow for academic progress with support. Choice D ('Severe') is incorrect as it does not align with the IQ level of 45, which falls within the 'Trainable' category.

3. A client with a history of seizures is prescribed phenytoin. Which side effect should the nurse instruct the client to report?

• A. Drowsiness
• B. Gingival hyperplasia
• C. Weight gain
• D. Blurred vision

Correct answer: B

Rationale: The correct answer is B: Gingival hyperplasia. Phenytoin is known to cause gingival hyperplasia, which is an overgrowth of gum tissue. This side effect is important to report to the healthcare provider because it can lead to oral health problems. Choice A, drowsiness, is a common side effect of many antiepileptic drugs but is not specific to phenytoin. Choice C, weight gain, is not a typical side effect of phenytoin. Choice D, blurred vision, is not a common side effect of phenytoin; it is more commonly associated with other medications.

4. The nurse prepares a teaching plan for an adult client with metabolic syndrome. Which findings should the nurse address to help the client reduce the risk for diabetes mellitus and vascular disease? (Select all that apply)

• A. Abdominal obesity
• B. Blood pressure of 150/96 mmHg
• C. Increased triglyceride levels
• D. All of the above

Correct answer: D

Rationale: The correct answer is D, as all the listed factors - abdominal obesity, high blood pressure, and increased triglyceride levels - are components of metabolic syndrome. Addressing these findings is crucial to help reduce the client's risk for developing diabetes mellitus and vascular disease. Abdominal obesity is a key feature of metabolic syndrome, high blood pressure (150/96 mmHg) is a risk factor, and increased triglyceride levels are also indicative of the syndrome. Educating the client on lifestyle modifications, such as healthy eating habits, regular physical activity, and monitoring these parameters, is essential in managing metabolic syndrome and preventing associated complications. Choices A, B, and C are all correct, making choice D the correct answer.

5. Laboratory findings indicate that a client’s serum potassium level is 2.5 mEq/L. What action should the nurse take?

• A. Administer potassium supplements orally.
• B. Increase the client's dietary potassium intake.
• C. Inform the healthcare provider of the need for potassium replacement.
• D. Monitor the client's ECG continuously.

Correct answer: C

Rationale: A serum potassium level of 2.5 mEq/L is critically low, indicating severe hypokalemia. In this situation, it is essential for the nurse to inform the healthcare provider promptly about the need for potassium replacement. Administering potassium supplements orally or increasing dietary potassium intake is not appropriate in cases of critically low potassium levels as immediate and precise replacement is necessary. Monitoring the client's ECG continuously is important in severe cases of hypokalemia, but the priority action should be to inform the healthcare provider for further management and treatment.

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