Nursing Elites

1. The client's B-type natriuretic peptide (BNP) level is 691 pg/mL. Which intervention should the nurse implement when providing care for the client?

• A. Take daily weights and monitor trends.
• B. Encourage fluid intake to improve hydration.
• C. Elevate the legs above the level of the heart.
• D. Position the client supine with the head of the bed at 30 degrees.

Correct answer: A

Rationale: Elevated BNP levels are indicative of heart failure, which often causes fluid retention and weight gain. Taking daily weights and monitoring trends allows the nurse to assess for changes in fluid status. This intervention helps in evaluating the effectiveness of the treatment plan and identifying worsening heart failure symptoms early. Encouraging fluid intake (Choice B) might exacerbate fluid overload in a client with elevated BNP levels. Elevating the legs (Choice C) and positioning the client supine with the head of the bed at 30 degrees (Choice D) are interventions more suitable for clients with hypotension, not specifically indicated for managing elevated BNP levels.

2. A client with heart failure is prescribed furosemide (Lasix). The nurse should monitor the client for which potential electrolyte imbalance?

• A. Hyperkalemia
• B. Hypernatremia
• C. Hypokalemia
• D. Hypocalcemia

Correct answer: C

Rationale: When a client with heart failure is prescribed furosemide, the nurse should monitor for hypokalemia. Furosemide is a loop diuretic that can lead to potassium loss, which increases the risk of hypokalemia. Hypokalemia can have serious implications such as cardiac dysrhythmias. Therefore, it is essential to closely monitor the client's serum potassium levels while on furosemide to prevent complications. Hyperkalemia (Choice A) is incorrect because furosemide leads to potassium loss, not retention. Hypernatremia (Choice B) is not typically associated with furosemide use. Hypocalcemia (Choice D) is not a common electrolyte imbalance caused by furosemide.

3. The LPN/LVN is assisting with the care of a client who has been diagnosed with a myocardial infarction (MI). Which laboratory test result would the nurse expect to see elevated within the first 24 hours of the client's admission?

• A. Serum troponin
• B. Serum creatinine
• C. Serum sodium
• D. Serum albumin

Correct answer: A

Rationale: Elevated serum troponin levels are indicative of myocardial damage and are commonly used as a diagnostic marker for myocardial infarction. Troponin levels typically rise within a few hours of an MI and remain elevated for several days, making it a crucial test for early detection and monitoring of cardiac injury. Serum creatinine is not typically elevated in the acute phase of a myocardial infarction. Serum sodium and serum albumin levels are not directly associated with myocardial infarction and are unlikely to be elevated in the first 24 hours following an MI.

4. A client is diagnosed with thrombophlebitis. The nurse should tell the client that which prescription is indicated?

• A. Bed rest, with bathroom privileges only
• B. Bed rest, keeping the affected extremity flat
• C. Bed rest, with elevation of the affected extremity
• D. Bed rest, with the affected extremity in a dependent position

Correct answer: C

Rationale: The correct answer is C: Bed rest, with elevation of the affected extremity. Elevating the affected extremity is crucial in managing thrombophlebitis as it helps reduce swelling and promotes venous return. By elevating the affected extremity, the gravitational force assists in venous blood flow back to the heart, thereby reducing the risk of complications associated with thrombophlebitis. Choices A, B, and D are incorrect because they do not address the need for elevation, which is specifically beneficial in the management of thrombophlebitis.

5. A client with schizophrenia taking clozapine is being assessed by a nurse. Which of the following findings is the priority for the nurse to report to the provider?

• A. Elevated blood pressure
• B. Fever
• C. Weight gain
• D. Dry mouth

Correct answer: B

Rationale: The priority finding for the nurse to report to the provider is B: Fever. Fever can be an indication of agranulocytosis, a potentially life-threatening condition associated with clozapine. Agranulocytosis is characterized by a significant decrease in white blood cells, making the client susceptible to severe infections. Prompt reporting of fever is crucial to prevent serious complications. Elevated blood pressure (Choice A), weight gain (Choice C), and dry mouth (Choice D) are important to monitor but are not as immediately concerning as fever, which could indicate a severe adverse reaction requiring urgent medical attention.

Similar Questions