Nursing Elites

1. A nurse is caring for a client who has been diagnosed with hyperkalemia. Which of the following findings should the nurse expect?

• A. Muscle weakness
• B. Nausea
• C. Increased thirst
• D. Restlessness

Correct answer: A

Rationale: Muscle weakness is a characteristic finding in hyperkalemia. High levels of potassium can affect the normal function of muscles, leading to weakness. Nausea and increased thirst are not typically associated with hyperkalemia. Restlessness is more commonly seen in conditions such as hypoxia or anxiety, not specifically in hyperkalemia.

2. What is the first step in managing a patient with a suspected pneumothorax?

• A. Insert a chest tube
• B. Monitor respiratory status
• C. Administer oxygen
• D. Call for assistance

Correct answer: A

Rationale: The correct answer is to insert a chest tube. In managing a patient with a suspected pneumothorax, the priority is to relieve the pressure from the pneumothorax by inserting a chest tube. Monitoring respiratory status (choice B) is important but comes after ensuring proper management of the pneumothorax. Administering oxygen (choice C) can help support oxygenation but does not address the underlying issue of pressure in the thoracic cavity. Calling for assistance (choice D) can be done concurrently with managing the pneumothorax, but the immediate intervention to address the pneumothorax itself is chest tube insertion.

3. What are the key components of a focused respiratory assessment, and how do you recognize signs of respiratory distress?

• A. Inspection, Palpation, Percussion, Auscultation
• B. Palpation, Inspection, Observation, Auscultation
• C. Percussion, Inspection, Auscultation, Palpation
• D. Inspection, Percussion, Auscultation, Palpation

Correct answer: A

Rationale: The correct answer is A: Inspection, Palpation, Percussion, Auscultation. A focused respiratory assessment should start with inspection (observing the breathing pattern), followed by palpation (feeling for abnormalities like crepitus), percussion (evaluating for dullness or hyperresonance), and auscultation (listening to lung sounds). This systematic approach helps to identify signs of respiratory distress, such as abnormal breath sounds, increased respiratory rate, use of accessory muscles, and cyanosis. Choices B, C, and D are incorrect because they do not follow the standard order and sequence of a focused respiratory assessment.

4. Which of the following is an early indication that a tracheostomy client requires suctioning?

• A. Bradycardia
• B. Irritability
• C. Hypotension
• D. Decreased respiratory rate

Correct answer: B

Rationale: Irritability is indeed an early sign that a tracheostomy client may require suctioning. When a tracheostomy client becomes irritable, it can indicate that there is a need for suctioning to clear the airway. Bradycardia (choice A) refers to a slow heart rate and is not typically a direct indication for suctioning. Hypotension (choice C) indicates low blood pressure and is not specifically related to the need for suctioning. Decreased respiratory rate (choice D) can be a sign of respiratory distress, but irritability is a more direct and early indication of the need for suctioning in a tracheostomy client.

5. A nurse is contributing to the plan of care for a client following a transurethral resection of the prostate (TURP). Which of the following interventions should the nurse include?

• A. Administer antibiotics
• B. Irrigate the bladder using sterile technique
• C. Avoid irrigating the bladder
• D. Insert a urinary catheter

Correct answer: B

Rationale: Irrigating the bladder using sterile technique is crucial in the care of a client following a transurethral resection of the prostate (TURP). This intervention helps prevent infection and maintains patency of the urinary catheter, promoting healing. Administering antibiotics (Choice A) may be necessary if there is an infection present, but it is not a routine intervention following TURP. Avoiding bladder irrigation (Choice C) is not recommended as it can lead to clot retention and other complications. Inserting a urinary catheter (Choice D) is usually already done during the TURP procedure and is not a postoperative intervention.

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