Nursing Elites

1. Which of the following assessments is the most important for a patient receiving IV potassium?

• A. Respiratory rate
• B. Heart rate
• C. Blood pressure
• D. Oxygen saturation

Correct answer: C

Rationale: The most important assessment for a patient receiving IV potassium is monitoring blood pressure. IV potassium can cause significant changes in cardiac function, leading to adverse effects such as arrhythmias and cardiac arrest. While respiratory rate, heart rate, and oxygen saturation are important parameters to monitor in clinical practice, blood pressure takes precedence in patients receiving IV potassium due to its direct impact on cardiovascular function. Changes in blood pressure can be an early indicator of potassium-induced cardiac complications, making it crucial to monitor closely during administration.

2. A client is experiencing diarrhea. For which acid-base disorder should the nurse assess the client?

• A. Metabolic acidosis
• B. Metabolic alkalosis
• C. Respiratory acidosis
• D. Respiratory alkalosis

Correct answer: A

Rationale: When a client experiences diarrhea, the loss of bicarbonate-rich fluids from the body leads to a decrease in the bicarbonate levels in the blood, resulting in metabolic acidosis. Metabolic alkalosis (choice B) is characterized by an increase in bicarbonate levels, which is not typically associated with diarrhea. Respiratory acidosis (choice C) is caused by retention of carbon dioxide, while respiratory alkalosis (choice D) results from excessive exhalation of carbon dioxide, neither of which are directly related to diarrhea. Therefore, the correct answer is metabolic acidosis (choice A) in the context of diarrhea.

3. When obtaining the health history of a client suspected of having bladder cancer, which question should the nurse ask to determine the client's risk factors?

• A. Do you smoke cigarettes?
• B. Do you consume alcohol?
• C. Do you use recreational drugs?
• D. Do you take any prescription drugs?

Correct answer: A

Rationale: The correct answer is A: 'Do you smoke cigarettes?' Smoking is a major risk factor for bladder cancer. Cigarette smoke contains harmful chemicals that can accumulate in the urine and damage the lining of the bladder, increasing the risk of developing cancer. Alcohol use, recreational drug use, and most prescription drugs are not directly linked to an increased risk of bladder cancer. It is important for the nurse to assess smoking history as a significant risk factor in determining the client's risk for bladder cancer.

4. A client who underwent preadmission testing 1 week before surgery had blood drawn for several serum laboratory studies. Which abnormal laboratory results should the nurse report to the surgeon’s office? Select all that apply.

• A. Hematocrit 30%
• B. Sodium 141 mEq/L
• C. Hemoglobin 8.9 g/dL
• D. Platelets 210,000 cells/mm3

Correct answer: C

Rationale: The correct answer is C. Hemoglobin level of 8.9 g/dL is below the normal range, indicating anemia. Anemia can affect the body's ability to carry oxygen, impacting surgical outcomes. Hematocrit level is an indirect measure of red blood cells, which also reveals anemia when low. Sodium level of 141 mEq/L and platelet count of 210,000 cells/mm3 are within normal ranges and do not require immediate reporting. Abnormal sodium levels can lead to various issues, but in this scenario, it is not a concern for surgical readiness. Platelet count is vital for blood clotting, and a count of 210,000 cells/mm3 is considered normal, so it does not need urgent attention.

5. Which of the following is the most important nursing action when administering a blood transfusion?

• A. Monitoring the patient's blood pressure.
• B. Monitoring the patient's temperature.
• C. Monitoring the patient's heart rate.
• D. Monitoring the patient's oxygen saturation.

Correct answer: A

Rationale: The most important nursing action when administering a blood transfusion is monitoring the patient's blood pressure. This is crucial because monitoring blood pressure allows for the prompt identification of any signs of adverse transfusion reactions, such as transfusion reactions or fluid overload. Immediate intervention can be initiated if any complications arise. While monitoring temperature, heart rate, and oxygen saturation are also essential aspects of patient care, they are not as critical as blood pressure monitoring during a blood transfusion. Therefore, the correct answer is to monitor the patient's blood pressure.

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