Nursing Elites

1. A client with bladder cancer who underwent a complete cystectomy with ileal conduit is being assessed by a nurse. Which assessment finding should prompt the nurse to urgently contact the healthcare provider?

• A. The ileostomy is draining blood-tinged urine.
• B. There is serous sanguineous drainage on the surgical dressing.
• C. The ileostomy stoma appears pale and cyanotic.
• D. Oxygen saturations are 92% on room air.

Correct answer: C

Rationale: A pale or cyanotic appearance of the ileostomy stoma indicates compromised circulation, which can lead to necrosis if not promptly addressed. On the other hand, blood-tinged urine and serous sanguineous drainage are common following a complete cystectomy with ileal conduit. These findings do not typically indicate an urgent issue. An oxygen saturation of 92% on room air is slightly below the normal range but does not warrant urgent healthcare provider contact unless accompanied by significant respiratory distress or other concerning symptoms.

2. Which of the following is a common cause of acute kidney injury?

• A. Hypertension
• B. Dehydration
• C. Infection
• D. Hypotension

Correct answer: C

Rationale: Infection is a common cause of acute kidney injury because when the body fights an infection, it activates the immune response, leading to inflammation. This inflammatory response can affect the kidneys and impair their function. While hypertension (choice A) is a risk factor for chronic kidney disease, it is not a direct cause of acute kidney injury. Dehydration (choice B) can lead to prerenal acute kidney injury due to decreased blood flow to the kidneys, but infection is a more common cause of acute kidney injury. Hypotension (choice D) can contribute to prerenal acute kidney injury, but it is not a direct cause like infection.

3. A client who has heart failure is admitted with a serum potassium level of 2.9 mEq/L. Which action is most important for the nurse to implement?

• A. Administer 20 mEq of potassium chloride.
• B. Initiate continuous cardiac monitoring.
• C. Arrange a consultation with the dietitian.
• D. Educate about the side effects of diuretics.

Correct answer: B

Rationale: Hypokalemia, defined as a serum potassium level below the normal range of 3.5 to 5 mEq/L, can lead to changes in myocardial irritability and ECG waveform, potentially causing life-threatening dysrhythmias. Therefore, the priority action for the nurse is to initiate continuous cardiac monitoring to promptly detect any abnormal heart rhythms or ventricular ectopy. This monitoring is crucial for assessing the impact of potassium replacement therapy on the cardiac rhythm and ensuring the safety of the client. While administering potassium chloride is important for correcting the hypokalemia, it should occur after cardiac monitoring is in place. Consulting with a dietitian and educating about diuretic side effects are relevant aspects of care but are not the immediate priority in this situation where cardiac monitoring takes precedence for timely intervention.

4. During CPR, when attempting to ventilate a client's lungs, the nurse notes that the chest is not moving. What action should the nurse take first?

• A. Use a laryngoscope to check for a foreign body lodged in the airway.
• B. Reposition the head to ensure that the airway is properly opened.
• C. Turn the client to the side and administer three back blows.
• D. Perform a finger sweep of the mouth to clear any obstructions.

Correct answer: B

Rationale: The most common reason for inadequate lung aeration during CPR is the incorrect positioning of the head, leading to airway obstruction. Therefore, the initial action should be to reposition the head to open the airway properly and attempt to ventilate again. Using a laryngoscope to check for foreign bodies in the airway (Choice A) is not the first step and could delay crucial interventions. Turning the client to the side and administering back blows (Choice C) is not indicated in this scenario as the focus is on ventilating the lungs. Performing a finger sweep of the mouth (Choice D) is not recommended as it may push obstructions further into the airway during CPR.

5. A client with a chest tube attached to a closed drainage system has undergone a chest x-ray, which revealed that the affected lung is fully reexpanded. The nurse anticipates that the next assessment of the chest tube system will reveal:

• A. No fluctuation in the water seal chamber
• B. Continuous bubbling in the water seal chamber
• C. Increased drainage in the collection chamber
• D. Continuous gentle suction in the suction control chamber

Correct answer: A

Rationale: When the client's lung is fully reexpanded, the chest tube drainage system will no longer be actively draining, and there will be no fluctuation in the water seal chamber. Option B, continuous bubbling in the water seal chamber, indicates an air leak in the system, which is not expected when the lung is fully expanded. Option C, increased drainage in the collection chamber, would not be expected when the lung is reexpanded as there should be minimal to no drainage. Option D, continuous gentle suction in the suction control chamber, would not be appropriate when the lung is fully reexpanded and the chest tube is typically on a water seal system at this point to promote reexpansion and prevent air from entering the pleural space.

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