Nursing Elites

1. When assessing a male client, the nurse finds that he is fatigued and experiencing muscle weakness, leg cramps, and cardiac dysrhythmias. Based on these findings, the nurse plans to check the client’s laboratory values to validate the existence of which condition?

• A. Hyperphosphatemia
• B. Hypocalcemia
• C. Hypermagnesemia
• D. Hypokalemia

Correct answer: D

Rationale: The symptoms of fatigue, muscle weakness, leg cramps, and cardiac dysrhythmias are classic manifestations of hypokalemia. Potassium plays a vital role in muscle function and cardiac conduction, so a deficiency can lead to these symptoms. Checking the client’s laboratory values for potassium levels will help confirm the presence of hypokalemia.

2. While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement?

• A. Acknowledge that she is supporting the arm correctly.
• B. Encourage her to keep the joint uncovered to maintain warmth.
• C. Reinforce the need to grip directly under the joint for better support.
• D. Instruct her to grip directly over the joint for better motion.

Correct answer: A

Rationale: The wife is correctly performing the passive range-of-motion exercises by holding the arm above and below the elbow. The nurse should acknowledge this correct technique (A). It is essential to keep the joint uncovered (B) during exercises, while ensuring the rest of the body remains covered for warmth and privacy. Choices (C) and (D) do not provide optimal support to the joint for effective movement.

3. What is the most effective way to implement a teaching plan?

• A. Teach the information that the learner wants to learn first.
• B. Streamline the teaching plan to include only essential information.
• C. Present to the learner all the necessary information to meet the objectives.
• D. Provide the learner with written material to review before teaching sessions.

Correct answer: A

Rationale: The most effective way to implement a teaching plan is to teach the information that the learner wants to learn first. Teaching should be learner-centered, responding to the individual's needs and preferences. Learning is most successful when it addresses the specific interests and goals of the learner, as it increases motivation and engagement. By starting with what the learner is interested in, you can create a more effective and engaging learning experience.

4. What type of technique should the nurse observe when preparing to insert an indwelling catheter?

• A. Clean technique.
• B. Medical Asepsis.
• C. Isolation Protocol.
• D. Sterile Technique.

Correct answer: D

Rationale: When inserting an indwelling catheter, the nurse must observe sterile technique to minimize the risk of infections. Sterile technique involves using sterile equipment and maintaining a sterile field to prevent introducing pathogens into the urinary tract.

5. A client with stage 4 lung cancer receiving in-home hospice care expresses concerns about pain while the nurse is arranging for discharge. What action should the nurse take?

• A. Explain the potential respiratory issues associated with morphine use.
• B. Educate the family on assessing the effectiveness of analgesics.
• C. Suggest requesting a patient-controlled analgesic (PCA) pump from the healthcare provider.
• D. Provide the client with a schedule for around-the-clock prescribed analgesic use.

Correct answer: D

Rationale: In managing pain for a client with stage 4 lung cancer in hospice care, providing a schedule for around-the-clock prescribed analgesic use is essential. This approach ensures continuous pain control and helps prevent breakthrough pain. By having a consistent dosing schedule, the client can maintain a more stable level of pain relief, enhancing their comfort and quality of life during this critical time.

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