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The nurse is providing care for a client with heart failure who is prescribed furosemide. Which laboratory value should the nurse monitor closely?
- A. Calcium level
- B. Sodium level
- C. Magnesium level
- D. Potassium level
Correct Answer: D
Rationale: The correct answer is D: Potassium level. Furosemide is a loop diuretic that can cause potassium loss, leading to hypokalemia. Monitoring potassium levels is crucial to prevent complications such as cardiac arrhythmias. While calcium, sodium, and magnesium levels are important in various conditions and treatments, they are not the primary electrolyte affected by furosemide.
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Which strategy should the nurse implement when teaching a client with low literacy about a new diagnosis of hypertension?
- A. Provide a detailed handout with complex terms
- B. Use simple language and visual aids
- C. Encourage the client to research the diagnosis online
- D. Incorporate medical jargon to explain the condition
Correct Answer: B
Rationale: The correct strategy for teaching a client with low literacy about a new diagnosis of hypertension is to use simple language and visual aids. This approach helps ensure better understanding of the diagnosis and treatment plan by making the information clear and accessible. Providing a detailed handout with complex terms (Choice A) would not be suitable as it may confuse the client further. Encouraging the client to research the diagnosis online (Choice C) could lead to misinformation and overwhelm the client with information they may not understand. Incorporating medical jargon to explain the condition (Choice D) would not be helpful for a client with low literacy as it may complicate rather than clarify the information.
Prior to surgery, written consent must be obtained. What is the nurse's legal responsibility with regard to obtaining written consent?
- A. Witness the consent and sign the form as a witness
- B. Inform the client of alternatives to the procedure
- C. Explain the procedure in detail to the client
- D. Determine that the surgical consent form has been signed and is included in the client's record
Correct Answer: D
Rationale: The nurse's legal responsibility is to ensure that informed consent has been obtained by verifying that the client has signed the form and that it is included in the record. Witnessing the consent and signing as a witness is not the nurse's role, as this is typically done by a neutral party. Informing the client of alternatives to the procedure and explaining the procedure in detail are responsibilities of the healthcare provider performing the surgery, not the nurse.
The nurse is caring for a client with chronic renal failure who is receiving dialysis. The client reports muscle cramps and tingling in the hands. Which laboratory result should the nurse monitor to identify the cause of these symptoms?
- A. Sodium
- B. Calcium
- C. Phosphate
- D. Potassium
Correct Answer: B
Rationale: Muscle cramps and tingling in clients with chronic renal failure are often associated with hypocalcemia. Monitoring calcium levels is crucial to identify imbalances and manage symptoms appropriately. Sodium, phosphate, and potassium levels are important in renal failure but are not directly related to the symptoms of muscle cramps and tingling reported by the client.
A client with hypothyroidism is prescribed levothyroxine. What assessment finding suggests the medication is effective?
- A. Improved tolerance to cold.
- B. Decreased fatigue and improved energy levels.
- C. Reduced anxiety and improved mood.
- D. Increased sensitivity to heat.
Correct Answer: B
Rationale: The correct answer is B: Decreased fatigue and improved energy levels. Levothyroxine is a medication used to treat hypothyroidism by providing the body with the thyroid hormone it lacks. Therefore, a positive response to the medication would manifest as decreased fatigue and improved energy levels due to the correction of the thyroid hormone imbalance. Choices A, C, and D are incorrect because improved tolerance to cold, reduced anxiety, and increased sensitivity to heat are not direct indicators of the effectiveness of levothyroxine in managing hypothyroidism.
An unlicensed assistive personnel (UAP), who usually works on a surgical unit, is assigned to float to a pediatric unit. Which question by the charge nurse would be most appropriate when making delegation decisions?
- A. How long have you been a UAP and what units have you worked on?
- B. What type of care do you provide on the surgical unit, and what are the ages of the clients?
- C. What is your comfort level in caring for children and at what ages?
- D. Have you reviewed the list of expected skills you might need on this unit?
Correct Answer: D
Rationale: The most appropriate question by the charge nurse would be to ask the UAP if they have reviewed the list of expected skills needed on the pediatric unit. This ensures that the UAP is aware of the specific skills required for safe and appropriate care in that particular unit. Choices A, B, and C do not directly address the need for the UAP to review the expected skills, which is crucial for delegation decisions during floating assignments.