Nursing Elites

1. A nurse is reviewing the laboratory results of a client who has hypokalemia. Which of the following findings should the nurse expect?

• A. Serum potassium 5.4 mEq/L
• B. Flat T waves
• C. Elevated ST segments
• D. Bradycardia

Correct answer: B

Rationale: Flat T waves are a characteristic ECG finding in hypokalemia. Hypokalemia causes a decrease in serum potassium levels, leading to altered cardiac conduction. Flat T waves are associated with hypokalemia-induced cardiac dysrhythmias. Elevated ST segments are typically seen in conditions like myocardial infarction, not in hypokalemia. Bradycardia is not a typical manifestation of hypokalemia; instead, tachycardia may occur due to potassium imbalances affecting the heart's electrical activity.

2. A nurse is providing discharge teaching for a client who has an implantable cardioverter defibrillator. Which of the following statements demonstrates understanding of the teaching?

• A. I will soak in the tub rather than showering.
• B. I will wear loose clothing around my ICD.
• C. I will stop using my microwave oven at home because of my ICD.
• D. I can hold my cellphone on the same side of my body as the ICD.

Correct answer: B

Rationale: The correct answer is B. Wearing loose clothing around the ICD is essential to avoid putting pressure on the device, which can interfere with its function. Choices A, C, and D are incorrect. Soaking in a tub rather than showering is not relevant to ICD care. Stopping the use of a microwave oven is not necessary with an ICD. Holding a cellphone on the same side as the ICD is not recommended as it can potentially interfere with the device.

3. A nurse is caring for a client who is receiving enteral nutrition via a nasogastric tube. Which of the following actions should the nurse take to reduce the risk of aspiration?

• A. Position the client supine during feedings.
• B. Administer the feedings over 10 minutes.
• C. Elevate the head of the bed during feedings.
• D. Place the client in a lateral position after feedings.

Correct answer: C

Rationale: The correct action to reduce the risk of aspiration in clients receiving enteral feedings is to elevate the head of the bed during feedings. This position helps prevent regurgitation and aspiration of the feeding. Positioning the client supine (Choice A) increases the risk of aspiration as it promotes reflux. Administering feedings over 10 minutes (Choice B) does not directly reduce the risk of aspiration. Placing the client in a lateral position after feedings (Choice D) does not address the risk of aspiration during the feeding process.

4. A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?

• A. A client who was just given a glass of orange juice for a low blood glucose level.
• B. A client who is scheduled for a procedure in 1 hr.
• C. A client who has 100 mL of fluid remaining in his IV bag.
• D. A client who received a pain medication 30 min ago for postoperative pain.

Correct answer: A

Rationale: A client with low blood glucose levels needs immediate assessment to ensure stabilization. Hypoglycemia can lead to serious complications if not addressed promptly. The other options do not present immediate life-threatening situations that require urgent assessment. Option B can be attended to after addressing the client with low blood glucose levels. Option C can be managed based on the infusion rate and the client's condition. Option D, although important, can be assessed after ensuring the client with low blood glucose levels is stable.

5. A nurse is developing a care plan for a client who has paraplegia and has an area of nonblanchable erythema over the ischium. Which intervention should the nurse include?

• A. Place the client upright on a donut-shaped cushion.
• B. Teach the client to shift his weight every 15 minutes while sitting.
• C. Turn and reposition the client every 3 hours.
• D. Assess pressure points every 24 hours.

Correct answer: B

Rationale: The correct intervention for a client with nonblanchable erythema over the ischium is to teach the client to shift his weight every 15 minutes while sitting. This action helps relieve pressure on the affected area and prevents further skin breakdown. Placing the client upright on a donut-shaped cushion (Choice A) may not address the need for frequent weight shifts. Turning and repositioning the client every 3 hours (Choice C) is important for overall skin health but may not provide adequate relief for the specific area of nonblanchable erythema. Assessing pressure points every 24 hours (Choice D) is not frequent enough to prevent worsening of the skin condition in this case.

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