Nursing Elites

1. When assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate, which finding should the nurse report to the health care provider immediately?

• A. The bibasilar breath sounds are decreased.
• B. The patellar and triceps reflexes are absent.
• C. The patient has been sleeping most of the day.
• D. The patient reports feeling 'sick to my stomach.'

Correct answer: B

Rationale: The correct answer is B because the absence of patellar and triceps reflexes indicates potential magnesium toxicity, requiring immediate intervention. Nausea and lethargy are common side effects of elevated magnesium levels and should be reported, but they are not as critical as the loss of deep tendon reflexes. Decreased breath sounds suggest the need for coughing and deep breathing to prevent atelectasis, which is important but not as urgent as addressing magnesium toxicity.

2. A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the healthcare provider immediately that the patient is on which medication?

• A. Oral digoxin (Lanoxin) 0.25 mg daily
• B. Ibuprofen (Motrin) 400 mg every 6 hours
• C. Metoprolol (Lopressor) 12.5 mg orally daily
• D. Lantus insulin 24 U subcutaneously every evening

Correct answer: A

Rationale: The correct answer is A. Hypokalemia increases the risk for digoxin toxicity, which can lead to serious dysrhythmias. Therefore, with a low potassium level, the nurse should immediately alert the healthcare provider about the patient being on oral digoxin. Choices B, C, and D do not pose as much concern with the given potassium level. However, further assessment is still required for these medications.

3. The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be a priority for the nurse to report to the health care provider?

• A. Oral temperature of 100.1°F
• B. Serum sodium level of 138 mEq/L (138 mmol/L)
• C. Gradually decreasing level of consciousness (LOC)
• D. Weight gain of 2 pounds (1 kg) above the admission weight

Correct answer: C

Rationale: The priority assessment finding for the nurse to report to the healthcare provider is a gradually decreasing level of consciousness (LOC). This change in LOC could indicate fluid and electrolyte disturbances, which require immediate attention to prevent complications. While the other options such as an elevated temperature, serum sodium level, and weight gain are important to note and report, they do not indicate an urgent need for intervention compared to changes in LOC which could signify serious issues that need prompt evaluation and management.

4. Following a thyroidectomy, a patient complains of “a tingling feeling around my mouth.” Which assessment should the nurse complete immediately?

• A. Presence of the Chvostek’s sign
• B. Abnormal serum potassium level
• C. Decreased thyroid hormone level
• D. Bleeding on the patient’s dressing

Correct answer: A

Rationale: The correct assessment the nurse should complete immediately is checking for the presence of the Chvostek’s sign. The patient's complaint of tingling around the mouth is indicative of hypocalcemia, which can result from parathyroid injury/removal during thyroidectomy. The Chvostek’s sign is a clinical indication of hypocalcemia, where facial muscle twitching occurs when the facial nerve is tapped. Assessing serum potassium levels (choice B) is not the priority in this situation. While thyroid hormone levels (choice C) play a role in overall health, they do not directly relate to the patient’s current symptoms. Checking for bleeding on the dressing (choice D) is important but not the immediate priority when addressing potential hypocalcemia.

5. The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum total protein level. Which assessment finding indicates that the patient’s condition has improved?

• A. Hematocrit 28%
• B. Absence of skin tenting
• C. Decreased peripheral edema
• D. Blood pressure 110/72 mm Hg

Correct answer: C

Rationale: The decrease in peripheral edema indicates an improvement in the patient’s protein status. Edema is caused by low oncotic pressure in individuals with low serum protein levels. Good skin turgor is an indicator of fluid balance, not protein status. A low hematocrit could be caused by poor protein intake. Blood pressure does not provide a useful clinical tool for monitoring protein status.

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