Nursing Elites

1. Which medication should the nurse withhold if the client's blood pressure is 88/50?

• A. Rosuvastatin (Crestor)
• B. Enalapril (Vasotec)
• C. Digoxin (Lanoxin)
• D. Clopidogrel (Plavix)

Correct answer: B

Rationale: Enalapril (Vasotec) is the correct answer. It is an angiotensin-converting enzyme (ACE) inhibitor that can further lower blood pressure. Given that the client's blood pressure is already low at 88/50, administering Enalapril could exacerbate hypotension and compromise perfusion to vital organs. Rosuvastatin (Crestor), Digoxin (Lanoxin), and Clopidogrel (Plavix) are not contraindicated in the context of low blood pressure and may be administered safely.

2. While undergoing hemodialysis, the client becomes restless and tells the nurse he has a headache and feels nauseous. Which of the following complications does the nurse suspect?

• A. Infection.
• B. Disequilibrium syndrome.
• C. Air embolus.
• D. Infection.

Correct answer: C

Rationale: In this scenario, the client undergoing hemodialysis is experiencing symptoms like restlessness, a headache, and nausea. These symptoms are indicative of an air embolus, a serious complication that can occur during hemodialysis. Air embolus happens when air enters the bloodstream and can lead to symptoms like restlessness, a headache, and nausea. It is crucial for the nurse to suspect and address this complication promptly to prevent further harm to the client. Choices A and D (Infection) are less likely in this case, as the symptoms presented are more suggestive of an air embolus rather than an infection. Choice B (Disequilibrium syndrome) is also less likely as the symptoms described are not typical of this syndrome. Therefore, the correct answer is C: Air embolus.

3. Laboratory tests reveal the following electrolyte values for Mr. Smith: Na 135 mEq/L, Ca 8.5 mg/dL, Cl 102 mEq/L, and K 2.0 mEq/L. Which of the following values should the nurse report to the physician because of its potential risk to the client?

• A. Ca
• B. K
• C. Na
• D. Cl

Correct answer: B

Rationale: The correct answer is 'K.' Normal serum potassium levels range between 3.5 and 5.5 mEq/L. Mr. Smith's potassium level of 2.0 mEq/L is significantly below the normal range, indicating hypokalemia, which can lead to serious risks such as cardiac arrhythmias. The levels of sodium (Na), calcium (Ca), and chloride (Cl) are within normal ranges, so they do not pose an immediate risk to the client's health. Therefore, the nurse should report the low potassium level to the physician for prompt intervention.

4. Which of the following diseases or conditions is least likely to be associated with an increased potential for bleeding?

• A. metastatic liver cancer
• B. gram-negative septicemia
• C. pernicious anemia
• D. iron-deficiency anemia

Correct answer: C

Rationale: Pernicious anemia is least likely to be associated with an increased potential for bleeding. Pernicious anemia results from vitamin B12 deficiency due to a lack of intrinsic factor, leading to faulty absorption from the gastrointestinal tract. While pernicious anemia can lead to other health issues, bleeding tendencies are not a primary concern. Metastatic liver cancer (choice A) can cause liver dysfunction leading to decreased synthesis of clotting factors, increasing the risk of bleeding. Gram-negative septicemia (choice B) can lead to disseminated intravascular coagulation (DIC) causing excessive bleeding. Iron-deficiency anemia (choice D) can result in microcytic hypochromic red blood cells, which can impair oxygen transport and lead to tissue hypoxia, but it is not directly associated with a significant potential for bleeding.

5. A patient has been diagnosed with fibromyalgia and COPD. Which of the following tasks should the nurse delegate to a nursing assistant?

• A. Transferring the patient to the shower.
• B. Ambulating the patient for the first time.
• C. Taking the patient's breath sounds.
• D. Educating the patient on monitoring fatigue.

Correct answer: A

Rationale: The correct answer is to delegate the task of transferring the patient to the shower to a nursing assistant. Nursing assistants are trained to assist with transfers safely, making this task appropriate for delegation. Ambulating the patient for the first time involves assessing the patient's mobility and tolerance, which requires more assessment and monitoring by a nurse, especially in a patient with fibromyalgia and COPD. Taking the patient's breath sounds involves assessing the patient's respiratory status, which is a nursing responsibility due to the need for clinical judgment. Educating the patient on monitoring fatigue involves providing vital information and should be done by the nurse to ensure comprehensive understanding and tailored recommendations.

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