Nursing Elites

1. A nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.4 mEq/L. Which of the following would the nurse expect to note on the electrocardiogram as a result of the laboratory value?

• A. ST depression
• B. Inverted T wave
• C. Prominent U wave
• D. Tall peaked T waves

Correct answer: D

Rationale: The correct answer is 'Tall peaked T waves.' Tall peaked T waves are characteristic ECG changes associated with hyperkalemia. In hyperkalemia, the elevated potassium levels affect the myocardium, leading to changes in the ECG. ST depression (Choice A) is more commonly associated with myocardial ischemia or infarction. Inverted T wave (Choice B) is seen in conditions like myocardial ischemia or CNS events. Prominent U wave (Choice C) is typically associated with hypokalemia or certain medications. Therefore, in this scenario, the nurse would expect to note tall peaked T waves on the electrocardiogram due to the elevated potassium level.

2. Select the types of pain that are accurately coupled with an example of it. Select all that are correct.

• A. Radicular pain: Pain shooting down the leg from a herniated disc
• B. Central neuropathic pain: Pain from nerve damage after a stroke
• C. Peripheral neuropathic pain: Pain from diabetic neuropathy in the feet
• D. Chronic pain: Pain lasting for more than 3-6 months

Correct answer: D

Rationale: The correct answer is D because chronic pain is characterized by lasting for a prolonged period, typically more than 3-6 months, and is not necessarily related to acute injuries like a stab wound to the chest. Choices A, B, and C are incorrect because they do not accurately match the type of pain with its corresponding example. Radicular pain is pain that radiates along the nerve path, often from a pinched nerve or herniated disc, not a broken bone. Central neuropathic pain arises from damage to the central nervous system, such as after a stroke, not a leg injury. Peripheral neuropathic pain is caused by damage to the peripheral nerves, such as in diabetic neuropathy, not a fractured leg bone.

3. What are the fine, down-like hairs on the newborn's ears, shoulders, lower back, and/or forehead known as?

• A. Vernix.
• B. Lanugo.
• C. Milia.
• D. Vibrissae.

Correct answer: B

Rationale: Lanugo is the term used to describe the fine, down-like hairs found on a newborn's ears, shoulders, lower back, and/or forehead. These hairs are different from vernix, which is a waxy or cheese-like white substance covering the skin of newborns. Milia are small, white, or yellowish cysts that commonly appear on a newborn's face, while vibrissae are the thick, stiff hairs commonly found around the nose and other parts of the face.

4. You are caring for a patient with multiple trauma. Of all of these injuries and conditions, which is the most serious?

• A. A deviated trachea
• B. Gross deformity of a lower extremity
• C. Hematuria
• D. Decreased bowel sounds

Correct answer: A

Rationale: A deviated trachea is the most serious condition among the choices provided. It can indicate a tension pneumothorax, which is a life-threatening emergency requiring immediate intervention to prevent respiratory compromise. Choice B, a gross deformity of a lower extremity, while significant, is not as immediately life-threatening as a deviated trachea. Choice C, hematuria, may indicate kidney injury but is not as acutely life-threatening as a deviated trachea. Choice D, decreased bowel sounds, could indicate abdominal issues, but it is not as urgent or immediately life-threatening as a deviated trachea.

5. Who should document care?

• A. The LPNs should document the care that they provided and the care that was given by unlicensed assistive staff.
• B. The registered nurse must document all of the care that is provided by the nursing assistants because they are accountable for all care.
• C. All staff members should document all of the care that they have provided.
• D. All staff should document all of the care that they have provided but the registered nurse, as the only independent practitioner, signs it.

Correct answer: C

Rationale: All staff members should document the care they provided as part of their accountability and to ensure accurate and comprehensive records. In healthcare settings, it is essential for all staff to document the care they deliver for continuity of care and legal purposes. The registered nurse may sign off on the documentation for oversight purposes, but the responsibility of documenting care extends to all staff involved in patient care. Choices A and B incorrectly limit the responsibility to specific roles, while choice D inaccurately suggests that only the registered nurse signs off on the documentation, overlooking the importance of comprehensive documentation by all staff members involved.

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