Nursing Elites

1. Before administering an antibiotic that can cause nephrotoxicity, which lab value is most important for the nurse to review?

• A. Hemoglobin and Hematocrit
• B. Serum Calcium
• C. Serum Creatinine
• D. WBC

Correct answer: C

Rationale: The correct answer is C: Serum Creatinine. Serum creatinine is a key indicator of kidney function. Reviewing this value is crucial as it helps assess the client's risk for nephrotoxicity before administering the antibiotic. Elevated serum creatinine levels can indicate impaired kidney function, which would increase the risk of nephrotoxicity. Choices A, B, and D are not as directly related to kidney function and nephrotoxicity. Hemoglobin and hematocrit levels assess for anemia, serum calcium levels monitor calcium balance, and WBC count evaluates for infections. While these values are important for overall patient assessment, they are not as specific to assessing nephrotoxicity risk as serum creatinine.

2. When reinforcing diet teaching for a client diagnosed with hypokalemia, which foods should the PN encourage the client to eat? Select All That Apply

• A. Orange juice, oranges, bananas
• B. All are applicable
• C. Collard greens, kale, turnips
• D. Soybeans, lima beans, spinach

Correct answer: B

Rationale: The correct answer is B: All are applicable. Foods rich in potassium, such as orange juice, oranges, bananas, collard greens, kale, soybeans, lima beans, and spinach, are essential for managing hypokalemia. These options provide a significant source of potassium, which helps in maintaining normal heart and muscle function. Choice A is incorrect because it does not include all the appropriate potassium-rich foods. Choice C is incorrect as it only mentions vegetables rich in potassium, missing out on other essential sources like fruits and beans. Choice D is incorrect as it lacks key potassium-rich foods like oranges and bananas.

3. The nurse is preparing to provide wound care for a client. Which step should be done first?

• A. Don procedural gloves
• B. Remove the dressing
• C. Apply prescribed medications to the wound
• D. Don a pair of sterile gloves

Correct answer: A

Rationale: The correct answer is to don procedural gloves first. Donning procedural gloves is essential to protect the nurse from contaminants while removing the old dressing. This step helps maintain aseptic technique and prevents the transfer of microorganisms. Removing the dressing (choice B) should follow after wearing gloves to prevent the spread of pathogens. Applying prescribed medications (choice C) should be done after the wound is cleaned and dressed. Donning a pair of sterile gloves (choice D) is not necessary for initial wound care; procedural gloves are sufficient for standard wound care.

4. A female Native American client who is receiving chemotherapy places a native artifact, an Indian medicine wheel, in her hospital room. The HCP removes the medicine wheel and tells the client, 'This type of thing does not belong in the hospital.' Which intervention should the PN implement?

• A. Teach the client about the importance of adhering to the chemotherapy regimen
• B. Act as the client's advocate when addressing the issue with the HCP
• C. Consult with a Native American healer about the appropriate use of a medicine wheel
• D. Inform the HCP about the client's feelings of culture shock

Correct answer: B

Rationale: Acting as the client's advocate is the most appropriate intervention in this situation. Removing a culturally significant artifact without considering the client's beliefs and emotional needs can be distressing. By advocating for the client, the PN can ensure that the client's cultural practices are respected, which is crucial for her emotional and spiritual well-being during treatment. Choice A is incorrect because while chemotherapy adherence is important, it is not the most immediate concern in this scenario. The client's cultural needs and well-being take precedence. Choice C is incorrect because consulting with a Native American healer might not be necessary at this point and could delay addressing the immediate issue of advocating for the client's rights. Choice D is incorrect because simply reporting the client's feelings of culture shock to the HCP does not actively address the situation or advocate for the client's rights and cultural needs.

5. The PN notes that a UAP is ambulating a male client who had a stroke and has right-sided weakness. The UAP is walking on the client's left side. Which action should the PN take?

• A. Instruct the UAP to walk on the client's affected side
• B. Take over the ambulation and provide guidance to the UAP immediately
• C. Provide the client with an assistive device, such as a cane or walker
• D. Tell the UAP to take the client back to his room

Correct answer: A

Rationale: The correct action for the PN to take is to instruct the UAP to walk on the client’s affected side. This is essential to provide the necessary support and prevent falls, especially when the client has weakness on one side due to a stroke. Walking on the affected side helps provide stability and assistance to the weaker side. Choice B is incorrect because it would be more appropriate for the PN to provide immediate guidance and correct the UAP's positioning rather than taking over the task completely. Choice C is incorrect because while assistive devices may be beneficial, the immediate concern is the UAP's positioning during ambulation, not providing the client with an assistive device. Choice D is incorrect as there is no indication to return the client to his room unless it is necessary for his safety or well-being.

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