Nursing Elites

1. An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately?

• A. K+ 3.4 mEq/L (3.4 mmol/L)
• B. Ca+2 7.8 mg/dL (1.95 mmol/L)
• C. Na+ 154 mEq/L (154 mmol/L)
• D. PO4-3 4.8 mg/dL (1.55 mmol/L)

Correct answer: C

Rationale: The correct answer is C. The elevated serum sodium level (154 mEq/L) is consistent with the patient's neurologic symptoms of restlessness, agitation, and weakness, indicating a need for immediate action to prevent complications like seizures. The potassium level (3.4 mEq/L) and calcium level (7.8 mg/dL) are slightly off from normal but do not require immediate action. The phosphate level (4.8 mg/dL) is normal and not related to the symptoms presented by the patient.

2. The nurse in the emergency department observes a colleague viewing the electronic health record (EHR) of a client who holds an elected position in the community. The client is not a part of the colleague's assignment. Which action should the nurse implement?

• A. Communicate the colleague's actions to the unit charge nurse
• B. Send an email to facility administration reporting the action
• C. Write an anonymous complaint to a professional website
• D. Post a comment about the action on a staff discussion board

Correct answer: A

Rationale: Viewing the EHR of a client who is not under your care is a violation of HIPAA regulations, regardless of the client's social status or your curiosity. The appropriate action to take in this situation is to communicate the colleague's actions to the unit charge nurse. The charge nurse can then escalate the issue through the appropriate channels within the organization. Reporting to the charge nurse ensures that the incident is handled internally and in accordance with organizational policies and procedures. Sending an email to facility administration, writing an anonymous complaint to a professional website, or posting a comment on a staff discussion board are not the recommended actions as they may not address the issue effectively and could potentially violate confidentiality further.

3. At 01:00 on a male client's second postoperative night, the client states he is unable to sleep and plans to read until feeling sleepy. What action should the nurse implement?

• A. Leave the room and close the door to the client's room
• B. Assess the appearance of the client's surgical dressing
• C. Bring the client a prescribed PRN sedative-hypnotic
• D. Discuss symptoms of sleep deprivation with the client

Correct answer: A

Rationale: The client has a plan to read until feeling sleepy, indicating an intention to sleep. Therefore, offering a PRN sedative-hypnotic (C) is unnecessary, especially since it is a stronger sleep aid. Option (D) is not needed as the client already has a plan to address his sleeplessness. Assessing the surgical dressing (B) is not relevant to the client's immediate need for sleep. Leaving the room and closing the door (A) is the appropriate action to provide a conducive environment for the client to rest.

4. The nurse is caring for a patient who has a central venous access device (CVAD). Which action by the nurse is appropriate?

• A. Avoid using friction when cleaning around the CVAD insertion site.
• B. Use the push-pause method to flush the CVAD after giving medications.
• C. Obtain an order from the healthcare provider to change the CVAD dressing.
• D. Position the patient’s face away from the CVAD during injection cap changes.

Correct answer: B

Rationale: The correct answer is B because using the push-pause method to flush the CVAD after giving medications helps remove debris from the CVAD lumen and decreases the risk for clotting. Choice A is incorrect because friction should be used when cleaning the CVAD insertion site to decrease infection risk. Choice C is incorrect because obtaining an order from the healthcare provider to change the CVAD dressing is not necessary; the dressing should be changed when damp, loose, or visibly soiled. Choice D is incorrect because the patient should face away from the CVAD during cap changes to minimize the risk of contamination.

5. 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.

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