Nursing Elites

1. After 1 week of hospitalization, Mr. Gray develops hypokalemia. Which of the following is the most significant symptom of his disorder?

• A. Lethargy
• B. Increased pulse rate and blood pressure
• C. Muscle weakness
• D. Muscle irritability

Correct answer: C

Rationale: Muscle weakness is a hallmark symptom of hypokalemia. Hypokalemia refers to low levels of potassium in the blood, which can affect muscle function. The decreased potassium levels can lead to muscle weakness, cramping, and even paralysis. These symptoms can impact various muscle groups in the body, making muscle weakness the most significant symptom to monitor and address in patients with hypokalemia.

2. Which of the following is a sign or symptom of a hemolytic reaction to a blood transfusion?

• A. Hemoglobinuria
• B. Chest pain
• C. Urticaria
• D. Distended neck veins

Correct answer: A

Rationale: Hemoglobinuria is a characteristic sign of a hemolytic reaction to a blood transfusion. Hemolytic reactions can lead to the destruction of red blood cells, causing the release of hemoglobin into the urine, which presents as hemoglobinuria. Chest pain, urticaria, and distended neck veins are not specific signs of a hemolytic reaction and may be associated with other conditions or reactions.

3. In the emergency department, a nurse is assessing a client involved in a motor vehicle crash. Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg, heart rate 124/min, respirations 38/min, temperature 38.6 C (101.4 F), and SaO2 92% on room air. What action should the nurse take first?

• A. Obtain a chest X-ray.
• B. Prepare for chest tube insertion.
• C. Administer oxygen via high-flow mask.
• D. Initiate IV access.

Correct answer: C

Rationale: In this scenario, the client is presenting with signs of respiratory distress, including absent breath sounds, dyspnea, and a low SaO2 level. The priority action should be to improve oxygenation by administering oxygen via a high-flow mask. This intervention aims to increase the oxygen supply to the client's lungs, helping to address the hypoxemia. Once oxygenation is optimized, further interventions, such as obtaining a chest X-ray, preparing for chest tube insertion, or initiating IV access, can be considered based on the client's condition and healthcare provider's orders.

4. A nurse obtained a client’s pulse and found the rate to be above normal. The nurse documents this finding as:

• A. Tachypnea
• B. Hyperpyrexia
• C. Arrhythmia
• D. Tachycardia

Correct answer: D

Rationale: When a nurse finds a client's pulse rate to be above normal, it is documented as tachycardia. Tachycardia specifically refers to an elevated heart rate, while tachypnea is rapid breathing, hyperpyrexia is high fever, and arrhythmia is an irregular heartbeat. Therefore, the correct term to describe an above-normal pulse rate is tachycardia.

5. Which action would break sterile technique while preparing a sterile field for a dressing change?

• A. Using sterile forceps instead of sterile gloves to handle a sterile item
• B. Touching the outside wrapper of sterilized material without sterile gloves
• C. Placing a sterile object at the edge of the sterile field
• D. Pouring out a small amount of solution (15 to 30 ml) before pouring it into a sterile container

Correct answer: B

Rationale: Touching the outside wrapper of sterilized material without sterile gloves can introduce contaminants and compromise the sterility of the item. It is crucial to maintain strict adherence to sterile technique to prevent infections and ensure patient safety during procedures.

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