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. The nurse is reinforcing home care instructions with a client who is being discharged following a transurethral resection of the prostate (TURP). Which intervention is most important for the nurse to include in the client teaching?

• A. Avoid strenuous activity for 6 weeks.
• B. Report fresh blood in the urine.
• C. Take acetaminophen for a fever over 101°F.
• D. Consume 6 to 8 glasses of water daily.

Correct answer: B

Rationale: Reporting fresh blood in the urine is crucial as it may indicate postoperative complications requiring immediate attention. This symptom can be a sign of bleeding, infection, or other issues that need prompt medical evaluation. Avoiding strenuous activity for 6 weeks is important but not as urgent as reporting fresh blood. Taking acetaminophen for a fever over 101°F is relevant but addressing fresh blood in the urine takes precedence. Consuming an adequate amount of water daily is beneficial but not as critical as recognizing and reporting signs of potential complications.

3. The home health nurse is preparing to make daily visits to a group of clients. Which client should the nurse visit first?

• A. A client with congestive heart failure who reports a 3-pound weight gain in the last two days
• B. A client with a healing surgical wound
• C. A client requiring wound dressing change
• D. A client with stable vital signs needing medication administration

Correct answer: A

Rationale: The correct answer is A. A 3-pound weight gain in two days indicates fluid retention and worsening heart failure, which requires immediate assessment. This could be a sign of decompensation in the client's condition, necessitating prompt evaluation and intervention. Choices B, C, and D do not present an immediate threat to the client's health and can be addressed after assessing the client with congestive heart failure.

4. A client presents to the labor and delivery unit, screaming 'THE BABY IS COMING.' Which action should the nurse implement first?

• A. Observe the perineum
• B. Prepare the delivery room
• C. Call the obstetrician
• D. Administer pain relief

Correct answer: A

Rationale: Observing the perineum is the priority action for the nurse in this situation. It allows the nurse to assess the stage of labor, determine the urgency of the situation, and provide immediate assistance if the baby is indeed about to be delivered. Preparing the delivery room and calling the obstetrician can follow once the nurse has assessed the situation. Administering pain relief may not be the immediate priority when the baby is coming.

5. A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation. Which laboratory value should be monitored closely?

• A. Arterial blood gas (ABG) values
• B. Serum potassium level
• C. Serum sodium level
• D. Serum magnesium level

Correct answer: B

Rationale: The correct answer is B: Serum potassium level. In COPD, especially when the client is receiving diuretics or corticosteroids, monitoring serum potassium levels is crucial. These medications can lead to potassium loss, potentially causing hypokalemia. Arterial blood gas (choice A) values are important in assessing respiratory status but are not the primary concern related to medication side effects. Serum sodium (choice C) and magnesium (choice D) levels are also important, but in the context of COPD exacerbation and medication effects, potassium monitoring takes precedence.

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