Nursing Elites

1. 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.

2. What is the hallmark sign of intussusception?

• A. Mucus-like stools
• B. Currant jelly-like stools
• C. Tarry, black stools
• D. Green, soft stools

Correct answer: B

Rationale: The hallmark sign of intussusception is currant jelly-like stools, which result from the mixture of blood and mucus in the stool due to the sloughing of intestinal mucosa. Mucus-like stools (Choice A) are not typically associated with intussusception. Tarry, black stools (Choice C) are characteristic of gastrointestinal bleeding higher up in the gastrointestinal tract, such as from a peptic ulcer. Green, soft stools (Choice D) are more indicative of rapid transit through the intestines, possibly due to dietary factors or infections such as gastroenteritis.

3. A client is receiving a secondary infusion of erythromycin 1 gram in 100 mL dextrose 5% in water (D5W) to be infused in 45 minutes. How many mL/hour should the nurse program the infusion pump?

• A. 100 mL/hour.
• B. 125 mL/hour.
• C. 133 mL/hour.
• D. 150 mL/hour.

Correct answer: C

Rationale: To infuse 100 mL in 45 minutes, the infusion rate should be set to 133 mL/hour (100 mL / 0.75 hours). This calculation is obtained by dividing the total volume to be infused by the total time for infusion (100 mL / 0.75 hours = 133 mL/hour). Therefore, choice C is the correct answer. Choices A, B, and D are incorrect because they do not accurately calculate the infusion rate required to deliver the medication within the specified time frame.

4. An adolescent female asks the nurse about taking retinoic acid (Accutane). What guidance should be provided by the nurse?

• A. The medication should be used for 10 weeks only.
• B. The medication requires that sexually active females use contraception.
• C. The medication lowers hemoglobin levels very quickly.
• D. The medication has few side effects.

Correct answer: B

Rationale: The correct guidance the nurse should provide is that sexually active females must use contraception while taking Accutane and for 1 month after the 20 weeks it is prescribed. Choice A is incorrect because Accutane is typically taken for a longer duration than 10 weeks. Choice C is incorrect because Accutane does not lower hemoglobin levels quickly. Choice D is incorrect as Accutane is known for having many side effects, including the risk of birth defects.

5. Parents of a 5-year-old child diagnosed with cognitive impairment have come to the nurse to discuss different approaches to the ongoing care of their child. The nurse should suggest focusing on what activity?

• A. Acquiring job skills
• B. Making decisions
• C. Performing self-care activities
• D. Reading and doing simple math

Correct answer: C

Rationale: The correct answer is C: Performing self-care activities. For a 5-year-old child diagnosed with cognitive impairment, it is crucial to focus on teaching them basic self-care skills. This includes activities like dressing themselves, feeding, and personal hygiene. These skills are fundamental for their daily living and independence. Choices A, B, and D are not appropriate for a young child with cognitive impairment. Acquiring job skills is not developmentally suitable at this age, making decisions may be challenging due to cognitive limitations, and reading and doing simple math may be too advanced for their current cognitive abilities.

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