Nursing Elites

1. A client who is mouth breathing is receiving oxygen by face mask. The nursing assistant asks the nurse why a water bottle is attached to the oxygen tubing near the wall oxygen outlet. The nurse responds that the primary purpose of the water is to:

• A. Prevent the client from getting a nosebleed
• B. Give the client added fluid by way of the respiratory tree
• C. Humidify the oxygen that is bypassing the client’s nose
• D. Prevent fluid loss from the lungs during mouth breathing

Correct answer: C

Rationale: The purpose of the water bottle is to humidify the oxygen that is bypassing the nose during mouth breathing. When a client breathes through the mouth, the oxygen delivered by the face mask bypasses the natural humidification provided by the nasal passages. Therefore, the water bottle attachment helps to add moisture to the oxygen, preventing dryness and irritation to the respiratory tract. Choices A, B, and D are incorrect. Clients breathing through the mouth are not at risk for nosebleeds, do not receive added fluid through the respiratory tree, and do not experience fluid loss from the lungs due to mouth breathing.

2. The client with chronic renal failure is receiving hemodialysis. Which of the following laboratory values should the nurse monitor closely?

• A. Hemoglobin level.
• B. Blood urea nitrogen (BUN) level.
• C. Serum potassium level.
• D. Creatinine level.

Correct answer: C

Rationale: The serum potassium level should be monitored closely in clients undergoing hemodialysis due to the risk of hyperkalemia. Hemodialysis is used to remove waste products and excess electrolytes like potassium from the blood. Monitoring potassium levels is crucial because an imbalance can lead to serious cardiac complications, making it the priority value to monitor in this scenario. Monitoring hemoglobin levels (choice A) is important for anemia assessment in chronic renal failure but is not directly related to hemodialysis. Blood urea nitrogen (BUN) levels (choice B) and creatinine levels (choice D) are commonly monitored in renal function tests but are not the top priority for monitoring in a client undergoing hemodialysis.

3. A patient has a serum potassium level of 2.7 mEq/L. The patient’s provider has determined that the patient will need 200 mEq of potassium to replace serum losses. How will the nurse caring for this patient expect to administer the potassium?

• A. As a single-dose 200 mEq oral tablet
• B. As an intravenous bolus over 15 to 20 minutes
• C. In an intravenous solution at a rate of 10 mEq/hour
• D. In an intravenous solution at a rate of 45 mEq/hour

Correct answer: C

Rationale: For a patient with severe hypokalemia with a serum potassium level of 2.7 mEq/L requiring 200 mEq of potassium replacement, the appropriate route of administration would be intravenous. Potassium chloride should be administered slowly to prevent adverse effects; therefore, the correct option is to administer the potassium in an intravenous solution at a rate of 10 mEq/hour. Choices A and B are incorrect because potassium should not be given as a single-dose oral tablet or as an intravenous bolus over a short period of time due to the risk of adverse effects. Choice D is also incorrect as the rate of 45 mEq/hour exceeds the recommended maximum infusion rate for adults with a serum potassium level greater than 2.5 mEq/L, which is 10 mEq/hour.

4. A client tells the clinic nurse about experiencing burning on urination, and assessment reveals that the client had sexual intercourse four days ago with a person who was casually met. Which action should the nurse implement?

• A. Observe the perineal area for a chancroid-like lesion
• B. Obtain a specimen of urethral drainage for culture
• C. Assess for perineal itching, erythema, and excoriation
• D. Identify all sexual partners in the last four days

Correct answer: B

Rationale: Obtaining a urethral drainage specimen for culture is crucial in diagnosing a potential sexually transmitted infection (STI) in this client. While assessing for perineal symptoms like itching, erythema, and excoriation (Choice C) may provide additional information, obtaining a culture is more definitive. Observing for a chancroid-like lesion (Choice A) is not as pertinent as obtaining a culture for a broader diagnostic approach. Identifying all sexual partners in the last four days (Choice D) is important for contact tracing but obtaining a specimen for culture takes priority in this scenario.

5. A client with a chest tube attached to a closed drainage system has undergone a chest x-ray, which revealed that the affected lung is fully reexpanded. The nurse anticipates that the next assessment of the chest tube system will reveal:

• A. No fluctuation in the water seal chamber
• B. Continuous bubbling in the water seal chamber
• C. Increased drainage in the collection chamber
• D. Continuous gentle suction in the suction control chamber

Correct answer: A

Rationale: When the client's lung is fully reexpanded, the chest tube drainage system will no longer be actively draining, and there will be no fluctuation in the water seal chamber. Option B, continuous bubbling in the water seal chamber, indicates an air leak in the system, which is not expected when the lung is fully expanded. Option C, increased drainage in the collection chamber, would not be expected when the lung is reexpanded as there should be minimal to no drainage. Option D, continuous gentle suction in the suction control chamber, would not be appropriate when the lung is fully reexpanded and the chest tube is typically on a water seal system at this point to promote reexpansion and prevent air from entering the pleural space.

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