Nursing Elites

1. A patient diagnosed with hypokalemia is at risk for which condition?

• A. Cardiac dysrhythmias
• B. Muscle weakness
• C. Seizures
• D. Bradycardia

Correct answer: A

Rationale: Patients diagnosed with hypokalemia are at risk for cardiac dysrhythmias due to low potassium levels. Hypokalemia can lead to abnormalities in the electrical conduction system of the heart, potentially causing irregular heart rhythms. Muscle weakness (Choice B) is a symptom commonly associated with hypokalemia, but the question asks about conditions the patient is at risk for, not specific symptoms. Seizures (Choice C) are not typically associated with hypokalemia; they are more commonly linked with conditions such as epilepsy. Bradycardia (Choice D) refers to a slow heart rate, which is not a typical risk associated with hypokalemia; instead, tachycardia (fast heart rate) is more commonly observed in patients with low potassium levels.

2. A nurse is developing a plan of care for a client who will be placed in halo traction following surgical repair of the cervical spine. Which of the following interventions should the nurse include in the plan?

• A. Inspect the pin site every 4 hours
• B. Monitor the client's skin under the halo vest
• C. Ensure two personnel hold the halo device when repositioning the client
• D. Apply powder to the client's skin under the vest to decrease itching

Correct answer: B

Rationale: The correct answer is to monitor the client's skin under the halo vest. This is important to assess for signs of skin issues such as excessive sweating, redness, or blistering, which can lead to skin breakdown and infection. Choice A is incorrect because while inspecting the pin site is important, it should be done more frequently than every 4 hours. Choice C is incorrect as the halo device should be supported by the client's body weight, not personnel, when repositioning. Choice D is incorrect because applying powder frequently can increase the risk of skin irritation and infection.

3. If a nurse misread a glucose reading as 210 mg/dL instead of 120 mg/dL and administered insulin, what should the nurse monitor for?

• A. Monitor for hypoglycemia
• B. Monitor for hyperglycemia
• C. Administer glucose IV
• D. Document the incident

Correct answer: A

Rationale: The correct answer is to monitor for hypoglycemia. In this scenario, the nurse administered insulin based on an incorrect glucose reading, which could lead to a drop in blood sugar levels. Monitoring for hypoglycemia is crucial to prevent any adverse effects on the patient's health. Choice B, monitoring for hyperglycemia, is incorrect as the administration of insulin can lead to low blood sugar levels, not high. Choice C, administering glucose IV, is not the immediate action needed as monitoring for hypoglycemia comes first. Choice D, documenting the incident, is important but not the initial priority when patient safety is at risk.

4. What does continuous bubbling in the water seal chamber of a chest tube indicate?

• A. An air leak
• B. A blocked chest tube
• C. Normal chest tube function
• D. Continuous drainage from the chest tube

Correct answer: A

Rationale: Continuous bubbling in the water seal chamber of a chest tube indicates an air leak in the system. This occurs when air is entering the system through a leak, preventing the lung from fully re-expanding. Choice B, a blocked chest tube, is incorrect as a blocked tube would result in a lack of drainage rather than continuous bubbling. Choice C, normal chest tube function, is incorrect as continuous bubbling signifies an issue. Choice D, continuous drainage from the chest tube, is incorrect as bubbling in the water seal chamber specifically indicates an air leak, not just the presence of drainage.

5. What are the expected symptoms of a thrombotic stroke?

• A. Gradual loss of function on one side of the body
• B. Sudden loss of consciousness
• C. Severe headache and confusion
• D. Loss of sensation in the affected limb

Correct answer: A

Rationale: The correct answer is A: 'Gradual loss of function on one side of the body.' In a thrombotic stroke, a clot blocks a cerebral artery, leading to a gradual onset of symptoms such as weakness, numbness, or paralysis on one side of the body. Choice B, 'Sudden loss of consciousness,' is more characteristic of a hemorrhagic stroke. Choice C, 'Severe headache and confusion,' are often associated with subarachnoid hemorrhage rather than thrombotic stroke. Choice D, 'Loss of sensation in the affected limb,' is not a typical symptom pattern for a thrombotic stroke, which usually presents with motor deficits.

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