Nursing Elites

1. What are the key nursing interventions for a patient receiving diuretic therapy?

• A. Monitor electrolyte levels and administer potassium as needed
• B. Restrict fluid intake and provide a low-sodium diet
• C. Encourage oral fluids and increase dietary potassium
• D. Provide high-sodium foods to improve electrolyte balance

Correct answer: A

Rationale: The correct answer is A: Monitor electrolyte levels and administer potassium as needed. Patients on diuretic therapy are at risk of electrolyte imbalances, particularly low potassium levels. Monitoring electrolytes and administering potassium as needed are crucial nursing interventions to prevent imbalances. Choice B is incorrect because restricting fluid intake and providing a low-sodium diet are not typically indicated for patients on diuretic therapy. Choice C is incorrect as encouraging oral fluids and increasing dietary potassium can exacerbate electrolyte imbalances in patients on diuretics. Choice D is incorrect as providing high-sodium foods would worsen electrolyte balance issues in patients on diuretic therapy.

2. Which of the following interventions should the nurse implement for a client with hyperkalemia?

• A. Administer calcium gluconate
• B. Increase fluid intake to promote potassium excretion
• C. Administer a diuretic
• D. Administer sodium bicarbonate

Correct answer: A

Rationale: The correct intervention for a client with hyperkalemia is to administer calcium gluconate. Calcium gluconate helps counteract the effects of hyperkalemia by stabilizing the cardiac cell membrane. Increasing fluid intake (Choice B) may not effectively lower potassium levels. Administering a diuretic (Choice C) or sodium bicarbonate (Choice D) is not the primary treatment for hyperkalemia and may not address the immediate need to lower potassium levels.

3. A nurse is caring for a client who has coronary artery disease (CAD) and is receiving aspirin therapy. Which of the following findings should the nurse report to the provider?

• A. History of gastrointestinal bleeding
• B. Prothrombin time of 12 seconds
• C. Platelet count of 180,000/mm³
• D. Creatinine level of 1.0 mg/dL

Correct answer: A

Rationale: The correct answer is A: History of gastrointestinal bleeding. Aspirin therapy is contraindicated in clients with a history of gastrointestinal bleeding because aspirin can further increase the risk of bleeding. Option B, prothrombin time of 12 seconds, is within the normal range and does not indicate a concern related to aspirin therapy. Option C, platelet count of 180,000/mm³, is also within the normal range and does not suggest a need for reporting to the provider in the context of aspirin therapy. Option D, creatinine level of 1.0 mg/dL, is within the normal range and is not directly related to aspirin therapy in this scenario.

4. A nurse is reinforcing discharge teaching with a client who has dependent personality disorder. Which of the following instructions should the nurse include in the discharge teaching?

• A. Limit social interactions
• B. Demonstrate assertiveness
• C. Follow a rigid schedule
• D. Perform deep breathing exercises

Correct answer: B

Rationale: The correct answer is B: 'Demonstrate assertiveness.' For clients with dependent personality disorder, assertiveness training is crucial as it helps them become more independent and develop the skills to express their own needs and preferences effectively. Choice A ('Limit social interactions') is incorrect because promoting healthy social interactions is important for individuals with this disorder to build confidence and reduce dependency. Choice C ('Follow a rigid schedule') is incorrect as overly rigid schedules may exacerbate feelings of helplessness and dependence. Choice D ('Perform deep breathing exercises') is not directly related to addressing the core issues of dependent personality disorder, which primarily involve developing self-reliance and assertiveness.

5. A client is learning about preventing hip dislocation before total hip arthroplasty. Which instruction should be included?

• A. Avoid bending the hip more than 90 degrees
• B. Avoid lying on the unaffected side
• C. Avoid crossing the legs at the knees
• D. Avoid keeping the legs in a neutral position

Correct answer: C

Rationale: The correct instruction to prevent hip dislocation after total hip arthroplasty is to avoid crossing the legs at the knees. This position can put stress on the hip joint and increase the risk of dislocation. Choices A, B, and D are incorrect. Bending the hip more than 90 degrees, lying on the unaffected side, or keeping the legs in a neutral position are not directly related to preventing hip dislocation in this context.

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