Nursing Elites

1. While auscultating a client's heart sounds, which description should the nurse use to document a swishing sound related to blood turbulence or valvular defect?

• A. S1 S2
• B. S1 S2 S3
• C. Murmur
• D. Pericardial friction rub

Correct answer: C

Rationale: The correct answer is 'C: Murmur.' A murmur is auscultated as a swishing sound associated with blood turbulence caused by the heart or a valvular defect. Choices 'A: S1 S2' and 'B: S1 S2 S3' refer to normal heart sounds, specifically the closure of heart valves. 'D: Pericardial friction rub' is a dry, rubbing or grating sound caused by inflammation of the pericardial sac and is not associated with blood flow or valvular issues.

2. A client with type 1 diabetes is admitted with hypoglycemia. Which intervention should the nurse implement first?

• A. Administer 50% dextrose IV push
• B. Administer 15 grams of oral glucose
• C. Recheck the blood glucose level in 15 minutes
• D. Administer a glucagon injection

Correct answer: A

Rationale: Administering 50% dextrose IV push is the first priority in treating hypoglycemia to rapidly increase blood glucose levels. This choice is correct because in severe cases of hypoglycemia, when a client is admitted and unconscious or unable to swallow, intravenous administration of dextrose is crucial to quickly raise blood glucose levels. Option B, administering 15 grams of oral glucose, would be suitable for conscious clients with mild hypoglycemia who can swallow safely. Option C, rechecking blood glucose levels, should follow after immediate intervention to assess the response. Option D, administering a glucagon injection, is more suitable for cases where dextrose is not readily available or when the client does not respond to dextrose administration.

3. The nurse is caring for a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which laboratory value should be closely monitored?

• A. Serum potassium level
• B. Hemoglobin level
• C. White blood cell count
• D. Serum calcium level

Correct answer: A

Rationale: The correct answer is A: Serum potassium level. When a client with chronic kidney disease is receiving erythropoietin therapy, monitoring serum potassium levels is crucial due to the risk of developing hyperkalemia. Erythropoietin can stimulate red blood cell production, leading to an increase in potassium levels. Monitoring potassium helps prevent complications associated with hyperkalemia, such as cardiac arrhythmias. Choices B, C, and D are incorrect because while hemoglobin levels are relevant in assessing the effectiveness of erythropoietin therapy, monitoring potassium levels is more critical in this scenario.

4. A client with chronic kidney disease (CKD) is receiving erythropoietin therapy. Which laboratory value should the nurse monitor closely?

• A. Serum potassium
• B. Hemoglobin
• C. White blood cell count
• D. Serum creatinine

Correct answer: A

Rationale: The correct answer is A: Serum potassium. When a client with chronic kidney disease is receiving erythropoietin therapy, monitoring serum potassium closely is essential. Erythropoietin therapy can lead to increased red blood cell production, which may cause potassium levels to rise, potentially resulting in hyperkalemia. Monitoring potassium levels helps prevent complications associated with hyperkalemia. Choices B, C, and D are incorrect because they are not directly impacted by erythropoietin therapy in the context of CKD.

5. A client with chronic kidney disease (CKD) is receiving epoetin alfa (Epogen). Which laboratory value should the nurse monitor closely?

• A. Hemoglobin
• B. White blood cell count
• C. Serum potassium
• D. Serum creatinine

Correct answer: C

Rationale: The correct answer is C: Serum potassium. When a client with chronic kidney disease (CKD) is receiving epoetin alfa (Epogen), monitoring serum potassium levels closely is crucial. Epoetin alfa stimulates red blood cell production, which can lead to an increase in potassium levels. Hyperkalemia is a potential risk in these clients. Monitoring hemoglobin levels (choice A) is important in assessing the effectiveness of epoetin alfa therapy, but it is not the laboratory value that poses an immediate risk related to the medication. White blood cell count (choice B) and serum creatinine (choice D) are not directly affected by epoetin alfa therapy and are not the priority laboratory values to monitor in this case.

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