Nursing Elites

1. A client with a history of chronic kidney disease (CKD) is admitted with hyperkalemia. Which assessment finding requires immediate intervention?

• A. Peaked T waves on the ECG
• B. Bradycardia
• C. Decreased deep tendon reflexes
• D. Muscle weakness

Correct answer: A

Rationale: Peaked T waves on the ECG are a critical finding in hyperkalemia as they indicate potential life-threatening cardiac arrhythmias. Immediate intervention is necessary to prevent cardiac complications such as ventricular tachycardia or fibrillation. Bradycardia, decreased deep tendon reflexes, and muscle weakness are not typically associated with hyperkalemia and do not pose the same level of immediate risk to the client's life.

2. A client with diabetes mellitus is admitted with a blood glucose level of 640 mg/dl and is unresponsive. Which intervention should the nurse implement first?

• A. Administer 50% dextrose IV push
• B. Administer IV fluids as prescribed
• C. Check the client's blood glucose level
• D. Prepare the client for immediate dialysis

Correct answer: B

Rationale: Administering IV fluids as prescribed is the priority intervention in a client with a blood glucose level of 640 mg/dl and unresponsiveness. Severe hyperglycemia can lead to dehydration and electrolyte imbalances, and administering IV fluids can help manage hyperglycemia and prevent further complications. Administering dextrose IV push (Choice A) can exacerbate hyperglycemia in this scenario. Checking the client's blood glucose level (Choice C) is important but not the immediate priority when the client is unresponsive. Immediate dialysis (Choice D) is not indicated as the first intervention for hyperglycemia.

3. A client with a history of atrial fibrillation is receiving warfarin (Coumadin). Which assessment finding is most concerning?

• A. INR of 3.5
• B. Prothrombin time (PT) of 15 seconds
• C. Headache
• D. Blood pressure of 140/90 mmHg

Correct answer: C

Rationale: The correct answer is C. A headache in a client with a history of atrial fibrillation receiving warfarin (Coumadin) is concerning as it may indicate bleeding, which requires immediate assessment and intervention. Headaches can be a symptom of increased intracranial pressure due to bleeding, especially in patients on anticoagulants. Options A and B are within acceptable ranges for a client on warfarin therapy, indicating that the medication is effectively managing the clotting times. Option D, a blood pressure of 140/90 mmHg, while elevated, is not directly related to the client's condition of atrial fibrillation and warfarin therapy.

4. The practical nurse (PN) is assigned to work with three registered nurses (RNs) who are caring for neurologically compromised clients. The client with which change in status is best to assign to the PN?

• A. Diabetic ketoacidosis with a Glasgow Coma Scale score change from 10 to 7.
• B. Myxedema coma with a blood pressure change from 80/50 to 70/40.
• C. Viral meningitis with a temperature change from 101°F to 102°F.
• D. Subdural hematoma with a blood pressure change from 150/80 to 170/60.

Correct answer: C

Rationale: The client with viral meningitis and a temperature change is the most stable and appropriate for assignment to the PN. A change in temperature from 101°F to 102°F is not as critical as changes in Glasgow Coma Scale score, blood pressure, or wider blood pressure variations. The other clients require more complex monitoring and intervention due to their critical changes in status.

5. The nurse is caring for a client who is postoperative following a thyroidectomy. Which assessment finding is most concerning?

• A. Slight difficulty swallowing
• B. Hoarse voice
• C. Positive Chvostek's sign
• D. Pain at the incision site

Correct answer: C

Rationale: A positive Chvostek's sign is the most concerning assessment finding as it suggests hypocalcemia, which is a potential complication following thyroidectomy. Hypocalcemia can lead to serious complications such as tetany and laryngospasm. Immediate intervention is required to prevent further complications. Choices A, B, and D are common post-thyroidectomy findings and are expected during the immediate postoperative period. Slight difficulty swallowing may be due to postoperative swelling, a hoarse voice may be temporary due to intubation trauma, and pain at the incision site is normal after surgery.

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