Nursing Elites

1. Which lab value should be monitored in patients receiving furosemide?

• A. Monitor potassium levels
• B. Monitor sodium levels
• C. Monitor calcium levels
• D. Monitor glucose levels

Correct answer: A

Rationale: The correct answer is to monitor potassium levels in patients receiving furosemide. Furosemide is a loop diuretic that can lead to potassium loss in the urine, potentially causing hypokalemia. Monitoring potassium levels is crucial to prevent complications associated with low potassium levels, such as cardiac arrhythmias. Monitoring sodium levels (choice B) is not typically necessary with furosemide use, as it primarily affects potassium levels. Calcium levels (choice C) and glucose levels (choice D) are not directly impacted by furosemide and require monitoring for other conditions or medications.

2. A nurse is reviewing the medical record of a client who is 24 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

• A. Heart rate 90/min
• B. Serosanguineous drainage in the surgical drain
• C. Temperature 38.6°C (101.5°F)
• D. Urinary output 60 mL/hr

Correct answer: C

Rationale: The correct answer is C. A temperature of 38.6°C (101.5°F) is above the normal range and indicates a fever, which is a concerning finding postoperatively. Fever can be a sign of infection, so the nurse should report this finding to the provider for further evaluation and intervention. Choices A, B, and D are within expected parameters for a client who is 24 hours postoperative following abdominal surgery and do not require immediate reporting. A heart rate of 90/min, serosanguineous drainage in the surgical drain, and a urinary output of 60 mL/hr are all common postoperative findings that do not raise immediate concerns.

3. A healthcare provider is assessing a client who has pneumonia. Which of the following findings is the priority for the healthcare provider to report?

• A. Crackles in the lung bases
• B. Blood pressure of 100/64 mm Hg
• C. Respiratory rate of 26/min
• D. Heart rate of 86/min

Correct answer: C

Rationale: A respiratory rate of 26/min is a sign of respiratory distress and should be reported promptly in a client with pneumonia. Rapid breathing can indicate inadequate oxygenation and ventilation, which may lead to respiratory failure. Crackles in the lung bases are common in pneumonia but may not be as urgent as a high respiratory rate. A blood pressure of 100/64 mm Hg is slightly low but may not be immediately life-threatening. A heart rate of 86/min is within the normal range for an adult and is not the most critical finding to report.

4. A nurse is caring for a 1-day-old newborn who has jaundice and is receiving phototherapy. Which of the following actions should the nurse take?

• A. Feed the infant 30 ml (1 oz) of glucose water every 2 hours.
• B. Keep the infant's head uncovered.
• C. Ensure that the newborn wears a diaper.
• D. Apply lotion to the newborn every 4 hours.

Correct answer: C

Rationale: The correct action for the nurse to take is to ensure that the newborn wears a diaper. This is important to prevent irritation during phototherapy, as exposure to light can increase the risk of skin breakdown. Feeding the infant glucose water is unnecessary and not indicated for jaundice treatment. Keeping the infant's head uncovered allows the light to reach the skin effectively. Applying lotion to the newborn every 4 hours can interfere with the effectiveness of phototherapy and is not recommended.

5. A client with heart failure is receiving furosemide. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 80/min.
• B. Weight loss of 1.1 kg (2.5 lb) in 24 hours.
• C. Potassium level of 3.8 mEq/L.
• D. Urine output of 60 mL/hr.

Correct answer: B

Rationale: A weight loss of 1.1 kg (2.5 lb) in 24 hours may indicate dehydration or fluid imbalance, which should be reported. This rapid weight loss could be a sign of excessive diuresis, potentially leading to hypovolemia or electrolyte imbalances. Monitoring weight changes is crucial in clients with heart failure receiving diuretics. The other findings are within normal ranges and expected in a client receiving furosemide for heart failure. A heart rate of 80/min, a potassium level of 3.8 mEq/L, and a urine output of 60 mL/hr are generally acceptable in this scenario.

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