Nursing Elites

1. A client with acute kidney injury (AKI) is experiencing hyperkalemia. What intervention should the nurse prioritize?

• A. Administer IV calcium gluconate.
• B. Administer sodium polystyrene sulfonate (Kayexalate).
• C. Administer insulin with dextrose.
• D. Restrict potassium intake in the client's diet.

Correct answer: A

Rationale: The correct intervention for a client with acute kidney injury (AKI) experiencing hyperkalemia is to administer IV calcium gluconate. Calcium gluconate helps stabilize the myocardium and prevent life-threatening arrhythmias in hyperkalemia by antagonizing the cardiac effects of high potassium levels. Choice B, administering sodium polystyrene sulfonate (Kayexalate), is used to lower potassium levels in the gastrointestinal tract but is not the priority in acute severe hyperkalemia. Choice C, administering insulin with dextrose, helps drive potassium into cells but is not the priority in a client at risk for arrhythmias due to hyperkalemia. Choice D, restricting potassium intake in the client's diet, is a long-term strategy but is not the immediate priority in managing acute hyperkalemia.

2. An adult male is brought to the ER after a motorcycle accident with periorbital bruising and bloody drainage from both ears. Which finding requires immediate attention?

• A. Rebound abdominal tenderness.
• B. Diminished breath sounds bilaterally.
• C. Rib pain with deep inspiration.
• D. Projectile vomiting.

Correct answer: D

Rationale: In this scenario, the patient's periorbital bruising and bloody drainage from both ears suggest a severe head injury. Projectile vomiting is a red flag symptom that may indicate increased intracranial pressure, which requires immediate attention to prevent further neurological deterioration. Rebound abdominal tenderness (choice A) typically indicates peritonitis and is not directly related to the primary head injury. Diminished breath sounds bilaterally (choice B) suggest a pneumothorax or hemothorax, which are important but not as immediately life-threatening in this context. Rib pain with deep inspiration (choice C) is concerning for rib fractures or pulmonary contusion, which are also important but do not take precedence over addressing the potential increased intracranial pressure.

3. A client with cirrhosis is receiving spironolactone. What electrolyte level should the nurse monitor closely?

• A. Monitor potassium levels.
• B. Monitor sodium levels.
• C. Monitor calcium levels.
• D. Monitor magnesium levels.

Correct answer: A

Rationale: The correct answer is to monitor potassium levels. Spironolactone is a potassium-sparing diuretic, which means it helps the body retain potassium and excrete sodium. Monitoring potassium levels closely is essential because spironolactone can cause hyperkalemia (high potassium levels). Sodium levels are not typically affected by spironolactone. Calcium and magnesium levels are also not directly impacted by spironolactone, making choices B, C, and D incorrect.

4. What information should the nurse include in the client's health record after a fall in the bathroom?

• A. Client fell while trying to go to the bathroom
• B. The UAP left the client alone and a fall occurred
• C. The client was found on the floor with no pulse
• D. The client fell, sustaining a fracture to the left hip

Correct answer: D

Rationale: The correct answer is D because the nurse should document factual, objective information such as the injury sustained by the client. Reporting the specific injury, like a fracture to the left hip, is crucial for accurate medical records. Choices A, B, and C lack specific detail about the injury and focus on different aspects of the fall that are not as pertinent for the health record. Choice A only mentions the fall without specifying the injury, choice B introduces blame without focusing on the client's condition, and choice C adds unnecessary information about the client's pulse which is not directly related to the fall injury.

5. A client is admitted with ascites, malnutrition, and recent complaints of spitting up blood. What assessment finding warrants immediate intervention by the nurse?

• A. Capillary refill of 8 seconds
• B. Bruises on arms and legs
• C. Round and tight abdomen
• D. Pitting edema in lower legs

Correct answer: C

Rationale: A round and tight abdomen suggests fluid accumulation from ascites, which could signal a more severe underlying condition requiring immediate intervention. This finding indicates increased intra-abdominal pressure, which can lead to respiratory compromise or other serious complications. Capillary refill time, bruises on arms and legs, and pitting edema in the lower legs are important assessments but do not directly indicate the need for immediate intervention as a round and tight abdomen does in this case.

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