Nursing Elites

1. A nurse is caring for a client who has a new diagnosis of tuberculosis. Which of the following precautions should the nurse initiate to prevent transmission of the disease?

• A. Contact precautions
• B. Airborne precautions
• C. Droplet precautions
• D. Protective environment

Correct answer: B

Rationale: Tuberculosis is spread through small droplets measuring less than 5 microns, which can remain airborne for extended periods. The nurse should place a client who has TB under airborne precautions to prevent the spread of microbes. Choice A, contact precautions, are used for diseases spread by direct or indirect contact. Choice C, droplet precautions, are for diseases spread by larger droplets. Choice D, protective environment, is used for immunocompromised clients to protect them from environmental pathogens.

2. What is the preferred treatment for a patient with unstable angina admitted with chest pain?

• A. Administer sublingual nitroglycerin
• B. Establish IV access
• C. Auscultate heart sounds
• D. Obtain cardiac enzymes

Correct answer: A

Rationale: The correct answer is to administer sublingual nitroglycerin. Nitroglycerin helps vasodilate coronary arteries, improving blood flow to the heart, relieving chest pain, and preventing cardiac tissue damage. Establishing IV access (choice B) is important but not the preferred initial treatment for unstable angina with chest pain. Auscultating heart sounds (choice C) and obtaining cardiac enzymes (choice D) are relevant assessments but do not address the immediate symptomatic relief needed for a patient with unstable angina and chest pain.

3. What is the initial nursing action for a patient with a chest tube found to have an air leak?

• A. Check the tube connections
• B. Replace the chest tube
• C. Remove and reinsert the chest tube
• D. Document the incident

Correct answer: A

Rationale: When a patient with a chest tube is found to have an air leak, the priority action for the nurse is to check the tube connections. This step helps identify the source of the air leak, which can be caused by loose or disconnected tube connections. Once the source of the leak is identified and addressed, further interventions may be necessary. Replacing or removing and reinserting the chest tube should not be the initial response unless there are specific indications for these actions. Documenting the incident is important but comes after addressing the immediate concern of the air leak.

4. What are the expected ECG findings in hypokalemia?

• A. Flattened T waves
• B. Prominent U waves
• C. Elevated ST segments
• D. Wide QRS complex

Correct answer: A

Rationale: Flattened T waves are the classic ECG finding in hypokalemia. Hypokalemia primarily affects the repolarization phase of the cardiac action potential, leading to T wave abnormalities. While prominent U waves are typically associated with hypokalemia as well, flattened T waves are the most specific and sensitive ECG abnormality seen in hypokalemia. Elevated ST segments and wide QRS complexes are not typically seen in hypokalemia and are more indicative of other electrolyte imbalances or cardiac conditions.

5. When caring for a patient with hypokalemia, what should the nurse monitor for?

• A. Monitor for muscle weakness
• B. Check for cardiac dysrhythmias
• C. Monitor for bradycardia
• D. Monitor for seizures

Correct answer: A

Rationale: Corrected Answer: Muscle weakness is a common sign of hypokalemia. The nurse should monitor for muscle weakness as potassium plays a crucial role in muscle function. Choices B, C, and D are incorrect because although hypokalemia can lead to cardiac dysrhythmias, bradycardia, and even seizures in severe cases, muscle weakness is a more common and specific sign directly related to potassium levels.

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