Nursing Elites

1. The nurse is caring for a client with chronic renal failure who is receiving dialysis. The client reports muscle cramps and tingling in the hands. Which laboratory result should the nurse monitor to identify the cause of these symptoms?

• A. Sodium
• B. Calcium
• C. Phosphate
• D. Potassium

Correct answer: B

Rationale: Muscle cramps and tingling in clients with chronic renal failure are often associated with hypocalcemia. Monitoring calcium levels is crucial to identify imbalances and manage symptoms appropriately. Sodium, phosphate, and potassium levels are important in renal failure but are not directly related to the symptoms of muscle cramps and tingling reported by the client.

2. A client with Cushing's syndrome presents with excessive bruising and elevated blood glucose. What action should the nurse take first?

• A. Check the client's blood glucose level.
• B. Administer insulin per sliding scale protocol.
• C. Administer intravenous fluids.
• D. Check the client's skin for signs of bruising.

Correct answer: A

Rationale: Excessive bruising and elevated blood glucose are common symptoms of Cushing's syndrome. The nurse should first check the client's blood glucose level to assess and address the hyperglycemia promptly. Administering insulin or IV fluids would be premature without knowing the current blood glucose level. Checking the skin for bruising, although important for overall assessment, does not address the immediate concern of elevated blood glucose.

3. A client who has been prescribed multiple antihypertensive medications experiences syncope and has a blood pressure of 70/40. What is the rationale for the nurse to hold the next scheduled antihypertensive dose?

• A. Increased urinary clearance of the medications has produced diuresis, lowering the blood pressure.
• B. The antagonistic interaction of the medications has reduced their effectiveness.
• C. The synergistic effect of the medications has resulted in drug toxicity, causing hypotension.
• D. The additive effect of the medications has lowered the blood pressure too much.

Correct answer: D

Rationale: The additive effect of multiple antihypertensive medications can cause hypotension, leading to dangerously low blood pressure. In this scenario, the client experiencing syncope with a blood pressure of 70/40 indicates severe hypotension, likely due to the combined action of the antihypertensive medications. Holding the next scheduled dose is essential to prevent further lowering of blood pressure and potential complications. Choices A, B, and C provide inaccurate explanations and do not align with the client's presentation and the need to manage hypotension caused by the additive effect of the medications.

4. A client presents with a suspected infection and has a fever of 102°F. What is the nurse's immediate priority?

• A. Administer antipyretics as ordered
• B. Take a blood culture before administering antibiotics
• C. Encourage fluid intake to prevent dehydration
• D. Monitor vital signs every hour

Correct answer: B

Rationale: The immediate priority for a client with a suspected infection and fever is to take a blood culture before administering antibiotics. This step is crucial to identify the causative organism and ensure appropriate treatment. Administering antipyretics or encouraging fluid intake are important but should come after obtaining the blood culture to avoid interfering with test results. Monitoring vital signs, although essential, is not the immediate priority compared to identifying the infectious agent.

5. The client is being taught to choose foods rich in potassium to prevent digitalis toxicity. Which choice indicates the client understands dietary needs?

• A. Three apricots
• B. Medium banana
• C. Naval orange
• D. Baked potato

Correct answer: D

Rationale: The correct answer is D: Baked potato. Baked potatoes are rich in potassium, which is essential in preventing digitalis toxicity by helping to maintain normal electrolyte levels. Apricots, bananas, and oranges are also sources of potassium, but a baked potato has a higher potassium content compared to the other options, making it a more effective choice for preventing digitalis toxicity.

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