Nursing Elites

1. A client with a history of chronic kidney disease (CKD) is admitted with hyperkalemia. Which clinical finding is most concerning?

• A. Peaked T waves on the ECG
• B. Bradycardia
• C. Muscle weakness
• D. Decreased deep tendon reflexes

Correct answer: A

Rationale: Peaked T waves on the ECG are the most concerning finding in a client with hyperkalemia. Hyperkalemia can lead to serious cardiac complications, including arrhythmias and cardiac arrest. Peaked T waves are a classic ECG finding associated with hyperkalemia and indicate the need for immediate intervention. Bradycardia, muscle weakness, and decreased deep tendon reflexes can also be seen in hyperkalemia, but the presence of peaked T waves signifies a higher risk of cardiac events, making it the most concerning finding in this scenario.

2. Following routine diagnostic tests, a client who is symptom-free is diagnosed with Paget's disease. Client teaching should be directed toward what important goal for this client?

• A. Maintain adequate cardiac output.
• B. Promote adequate tissue perfusion.
• C. Promote rest and sleep.
• D. Reduce the risk for injury.

Correct answer: D

Rationale: In Paget's disease, bone remodeling is affected, leading to increased risk for fractures. Therefore, the primary goal of client teaching should focus on reducing the risk for injury. Choices A and B are not directly related to the primary concern of Paget's disease, which is bone fractures. Choice C, promoting rest and sleep, is important for overall health but is not the priority when considering the specific risks associated with Paget's disease.

3. The nurse observes an unlicensed assistive personnel (UAP) using an alcohol-based gel hand cleaner before performing catheter care. The UAP rubs both hands thoroughly for 2 minutes while standing at the bedside. Which action should the nurse take?

• A. Encourage the UAP to remain in the client's room until the procedure is completed.
• B. Explain that the hand rub can be completed in less than 2 minutes.
• C. Inform the UAP that handwashing helps to promote better asepsis.
• D. Determine why the UAP was not wearing gloves in the client's room.

Correct answer: B

Rationale: The correct answer is B. Explaining that hand rubs can be effective with less time allows the UAP to perform the procedure more efficiently while maintaining asepsis. Choice A is incorrect because the UAP does not need to remain in the client's room until the procedure is completed. Choice C is incorrect as the UAP was using an alcohol-based gel hand cleaner, not handwashing. Choice D is incorrect as the scenario does not mention any issue with glove usage, so it is not relevant to the situation at hand.

4. A client with rheumatoid arthritis is prescribed methotrexate. Which assessment finding requires immediate intervention?

• A. Fever of 100.4°F
• B. Positive Chvostek's sign
• C. Increased joint pain
• D. Swelling in the joints

Correct answer: B

Rationale: A positive Chvostek's sign indicates hypocalcemia, which requires immediate intervention as it can lead to life-threatening complications. Fever, increased joint pain, and swelling in the joints are common symptoms in clients with rheumatoid arthritis but do not require immediate intervention like addressing hypocalcemia.

5. A client is receiving continuous bladder irrigation via a triple-lumen suprapubic catheter that was placed during a prostatectomy. Which report by the unlicensed assistive personnel (UAP) requires intervention by the nurse?

• A. Leakage around the catheter insertion site.
• B. Pink-tinged urine in the drainage bag.
• C. Client reports discomfort at the catheter site.
• D. Decreased urine output in the last hour.

Correct answer: A

Rationale: The correct answer is A. Leakage around the catheter insertion site may indicate a problem with the catheter placement or function, requiring immediate intervention. Pink-tinged urine in the drainage bag is expected due to the continuous bladder irrigation. Discomfort at the catheter site is common after the procedure. Decreased urine output in the last hour may be due to the continuous bladder irrigation and doesn't require immediate intervention.

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