Nursing Elites

1. A nurse caring for a group of clients reviews the electrolyte laboratory results and notes a sodium level of 130 mEq/L on one client's laboratory report. The nurse understands that which client is at highest risk for the development of a sodium value at this level?

• A. The client with renal failure
• B. The client who is taking diuretics
• C. The client with hyperaldosteronism
• D. The client who is taking corticosteroids

Correct answer: B

Rationale: The correct answer is B. Clients taking diuretics are at risk for hyponatremia due to excessive sodium loss. In this scenario, a sodium level of 130 mEq/L indicates hyponatremia, which is commonly associated with diuretic use. Options A, C, and D are not the highest risk factors for developing low sodium levels in this context. Renal failure, hyperaldosteronism, and corticosteroid use are not directly linked to sodium loss as seen with diuretics.

2. A nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.4 mEq/L. Which of the following would the nurse expect to note on the electrocardiogram as a result of the laboratory value?

• A. ST depression
• B. Inverted T wave
• C. Prominent U wave
• D. Tall peaked T waves

Correct answer: D

Rationale: The correct answer is 'Tall peaked T waves.' Tall peaked T waves are characteristic ECG changes associated with hyperkalemia. In hyperkalemia, the elevated potassium levels affect the myocardium, leading to changes in the ECG. ST depression (Choice A) is more commonly associated with myocardial ischemia or infarction. Inverted T wave (Choice B) is seen in conditions like myocardial ischemia or CNS events. Prominent U wave (Choice C) is typically associated with hypokalemia or certain medications. Therefore, in this scenario, the nurse would expect to note tall peaked T waves on the electrocardiogram due to the elevated potassium level.

3. A nurse in a long-term care facility is caring for a client who reports the AP repositioned him in bed using excessive force. Which of the following actions should the nurse take?

• A. Document in the client's chart that an incident report has been filed.
• B. Contact the nurse manager.
• C. Reassure the client that the staff is well trained.
• D. Call risk management to interview the client.

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is to contact the nurse manager. By doing so, the nurse can escalate the issue appropriately, ensuring that the incident is addressed and necessary actions are taken. Documenting in the client's chart that an incident report has been filed (Choice A) may be necessary but should not be the first step. Reassuring the client that the staff is well trained (Choice C) does not address the client's concern and the need for intervention. Calling risk management to interview the client (Choice D) may be premature at this stage and should be handled by the nurse manager first.

4. A nurse is caring for a client who reports acute pain but refuses IM medication. The nurse distracts the client and quickly administers the injection. This illustrates which of the following?

• A. Assault
• B. False imprisonment
• C. Battery
• D. Libel

Correct answer: C

Rationale: The correct answer is C, 'Battery.' Administering the injection without the client's consent constitutes battery. Assault involves the threat of harm, not the actual act. False imprisonment is restraining a client against their will, which does not apply here. Libel refers to a false written statement, which is not relevant in this scenario.

5. Which statement about appendicitis is accurate and true?

• A. Appendicitis is more common among females than males.
• B. A high fiber diet is a risk factor associated with appendicitis.
• C. Left lower quadrant pain is suggestive of appendicitis.
• D. McBurney's point tenderness is suggestive of appendicitis.

Correct answer: D

Rationale: The correct answer is D: McBurney's point tenderness is suggestive of appendicitis. McBurney's point is located in the right lower abdomen and tenderness at this point is a classic sign of appendicitis. Choice A is incorrect as appendicitis is slightly more common in males than females. Choice B is incorrect as a high fiber diet is actually considered to be protective against appendicitis. Choice C is incorrect as appendicitis typically presents with pain in the right lower quadrant, not the left.

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