Nursing Elites

1. A patient with hypokalemia is being monitored. What should the nurse assess for?

• A. Muscle weakness
• B. Flattened T waves
• C. Checking deep tendon reflexes
• D. Seizures

Correct answer: A

Rationale: Corrected Question: A patient with hypokalemia is being monitored. What should the nurse assess for? Corrected Choice A: Muscle weakness Corrected Choice B: Flattened T waves Corrected Choice C: Checking deep tendon reflexes Corrected Choice D: Seizures Rationale: Hypokalemia is associated with muscle weakness due to the effect of low potassium levels on muscle function. Flattened T waves on an ECG are characteristic of hypokalemia but are not a direct assessment for the patient's condition. Checking deep tendon reflexes and seizures are not primary symptoms associated with hypokalemia, making them less relevant for monitoring a patient with this electrolyte imbalance.

2. 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.

3. What precaution should be advised to patients following cataract surgery?

• A. Wear dark glasses while outdoors
• B. Use warm compresses
• C. Avoid NSAIDs
• D. Avoid bright lights

Correct answer: A

Rationale: Patients who have undergone cataract surgery should wear dark glasses when outdoors to shield their eyes from light exposure, which can be uncomfortable or harmful during the recovery period. Using warm compresses (choice B) is not typically recommended after cataract surgery as it's more relevant for certain eye conditions. Avoiding NSAIDs (choice C) is advised to prevent bleeding complications, but it is not directly related to eye protection post-surgery. While avoiding bright lights (choice D) is crucial, wearing dark glasses provides a practical solution to achieve this, making choice A the most appropriate precaution.

4. What are the expected ECG changes in hypokalemia?

• A. Flattened T waves
• B. ST elevation
• C. Wide QRS complex
• D. Tall T waves

Correct answer: A

Rationale: Flattened T waves are the most common ECG change seen in patients with hypokalemia. Hypokalemia leads to a decrease in serum potassium levels, affecting the repolarization phase of the cardiac action potential. This results in T wave flattening or inversion. ST elevation is typically seen in conditions like myocardial infarction, not in hypokalemia. Wide QRS complex is more associated with hyperkalemia than hypokalemia. Tall T waves are often seen in hyperkalemia, not hypokalemia.

5. A nurse misreads a glucose level and administers insulin for a blood glucose of 210 mg/dL instead of 120 mg/dL. What is the priority intervention?

• A. Monitor for hypoglycemia
• B. Monitor for hyperkalemia
• 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 a misread glucose level, which could lead to hypoglycemia due to excessive insulin action lowering blood glucose levels. Monitoring for hypoglycemia allows for prompt recognition and intervention if blood glucose levels drop significantly. Choice B, monitoring for hyperkalemia, is incorrect as administering insulin would not cause hyperkalemia. Choice C, administering glucose IV, is not appropriate at this time since the patient's blood glucose level is already elevated. Choice D, documenting the incident, is important but not the priority at this moment when patient safety is at risk due to potential hypoglycemia.

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