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 and an unlicensed assistive personnel (UAP) are providing care for a client with a nasogastric tube (NGT) when the client begins to vomit. How should the nurse manage this situation?

• A. Direct the UAP to measure the emesis while the nurse irrigates the NGT
• B. Stop the NGT feed and notify the healthcare provider
• C. Increase the NGT suction pressure
• D. Elevate the head of the bed

Correct answer: A

Rationale: During vomiting in a client with an NGT, it is essential for the nurse to direct the UAP to measure the emesis to monitor the output. This helps in assessing the client's condition and response to treatment. Meanwhile, irrigating the NGT can be beneficial to relieve any obstruction that might be contributing to the vomiting. Stopping the NGT feed and notifying the healthcare provider (choice B) is important but not the immediate action needed. Increasing the NGT suction pressure (choice C) is unnecessary and can lead to complications. Elevating the head of the bed (choice D) is a general intervention to prevent aspiration but may not address the immediate issue of managing the vomiting episode and potential tube obstruction.

3. The nurse is caring for a client with end-stage renal disease (ESRD) who is scheduled for hemodialysis. Which assessment finding is most concerning?

• A. Blood pressure of 110/70 mmHg
• B. Heart rate of 110 beats per minute
• C. Fever of 100.4°F
• D. Respiratory rate of 24 breaths per minute

Correct answer: C

Rationale: A fever of 100.4°F is the most concerning assessment finding in a client with ESRD scheduled for hemodialysis. This elevation in temperature may indicate an underlying infection, which can lead to serious complications in individuals with compromised renal function. Prompt intervention is necessary to prevent the spread of infection and deterioration of the client's condition. The other vital signs mentioned, such as blood pressure, heart rate, and respiratory rate, while important to monitor, are within acceptable ranges and do not pose an immediate threat like a fever indicative of infection.

4. A client with type 1 diabetes is admitted with diabetic ketoacidosis (DKA). Which laboratory value is most concerning?

• A. Serum glucose of 300 mg/dl
• B. Serum bicarbonate of 18 mEq/L
• C. Serum potassium of 5.5 mEq/L
• D. Serum sodium of 135 mEq/L

Correct answer: C

Rationale: A serum potassium level of 5.5 mEq/L is concerning in a client with DKA as it may indicate worsening hyperkalemia, requiring immediate intervention. Elevated serum potassium levels can lead to life-threatening cardiac arrhythmias. While elevated glucose and low bicarbonate are characteristic of DKA, hyperkalemia poses a higher immediate risk. Serum sodium within the normal range is not typically a primary concern in DKA.

5. The nurse is assessing a client with left-sided heart failure. Which clinical finding requires immediate intervention?

• A. Jugular venous distention
• B. Shortness of breath
• C. Crackles in the lungs
• D. Peripheral edema

Correct answer: C

Rationale: Corrected Rationale: In a client with left-sided heart failure, crackles in the lungs are the most concerning finding as they indicate pulmonary congestion, which requires immediate intervention to prevent worsening heart failure symptoms and respiratory distress. Jugular venous distention, shortness of breath, and peripheral edema are also common in heart failure but are not as critical as crackles in the lungs because they may indicate fluid overload or right-sided heart failure, which are important to address but not as urgently as managing pulmonary congestion.

Similar Questions