Nursing Elites

1. The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately?

• A. Blood urea nitrogen 50 mg/dl
• B. Hemoglobin of 10.3 g/dl
• C. Venous blood pH 7.30
• D. Serum potassium 6 mEq/L

Correct answer: D

Rationale: A serum potassium level of 6 mEq/L indicates hyperkalemia, which can be life-threatening and requires immediate intervention. Hyperkalemia can lead to dangerous cardiac arrhythmias and must be addressed promptly. The other options are not as urgent. A blood urea nitrogen level of 50 mg/dl may indicate kidney dysfunction but does not require immediate intervention. Hemoglobin of 10.3 g/dl may suggest anemia, which needs management but is not an immediate threat. A venous blood pH of 7.30 may indicate acidosis, which is concerning but not as acutely dangerous as hyperkalemia.

2. A client is receiving treatment for hypothyroidism. Which of these assessments would be most concerning to the nurse?

• A. Heart rate of 70 beats per minute
• B. Blood pressure of 110/70 mm Hg
• C. Respiratory rate of 16 breaths per minute
• D. Temperature of 98.6 degrees Fahrenheit

Correct answer: B

Rationale: A blood pressure of 110/70 mm Hg would be most concerning to the nurse because changes in blood pressure can indicate worsening hypothyroidism, potentially leading to complications such as myxedema coma. A heart rate of 70 beats per minute, a respiratory rate of 16 breaths per minute, and a temperature of 98.6 degrees Fahrenheit are within normal ranges and not typically directly associated with hypothyroidism complications.

3. A client has a chest tube in place following a left lower lobectomy inserted after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action?

• A. Clamp the chest tube
• B. Call the surgeon immediately
• C. Prepare for blood transfusion
• D. Continue to monitor the rate of drainage

Correct answer: D

Rationale: In this scenario, the most appropriate nursing action is to continue to monitor the rate of drainage. Clamping the chest tube is not recommended as it can lead to a tension pneumothorax. Calling the surgeon immediately may not be necessary at this point unless the drainage rate significantly increases or other concerning symptoms develop. Preparing for a blood transfusion is premature without further assessment and monitoring of the client's condition. Monitoring the rate of drainage allows the nurse to assess for any potential complications and ensure that the drainage amount is within expected limits.

4. When another nurse enters the room in response to a call, after checking the client's pulse and respirations during CPR on an adult in cardiopulmonary arrest, what should be the function of the second nurse?

• A. Relieve the nurse performing CPR
• B. Go get the code cart
• C. Participate with the compressions or breathing
• D. Validate the client's advanced directive

Correct answer: C

Rationale: The correct answer is to participate in compressions or breathing. This is essential to ensure continuous and effective CPR. Relieving the nurse performing CPR (Choice A) is not recommended as it can interrupt the life-saving procedure. Going to get the code cart (Choice B) may be necessary in certain situations but should not take precedence over providing immediate assistance in CPR. Validating the client's advanced directive (Choice D) is not the primary role in this scenario where urgent action is needed to support the client's circulation and breathing.

5. In a client with chronic kidney disease having a serum potassium level of 6.5 mEq/L, which assessment is the most critical for the nurse to perform?

• A. Neurological status
• B. Cardiac status
• C. Respiratory status
• D. Gastrointestinal status

Correct answer: B

Rationale: Corrected Rationale: Assessing cardiac status is crucial in hyperkalemia as high potassium levels can result in life-threatening arrhythmias. Monitoring the heart rhythm and ECG findings is essential to prevent cardiac complications. Neurological status, respiratory status, and gastrointestinal status are important assessments too, but in the context of hyperkalemia, cardiac status takes precedence due to the immediate risk of cardiac arrhythmias.

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