Nursing Elites

1. The nurse is caring for a client with a chest tube following a pneumothorax. Which assessment finding requires immediate intervention?

• A. Oxygen saturation of 94%
• B. Subcutaneous emphysema
• C. Crepitus around the insertion site
• D. Drainage of 50 ml per hour

Correct answer: B

Rationale: Subcutaneous emphysema is the correct answer as it is most concerning in a client with a chest tube following a pneumothorax. It may indicate a pneumothorax recurrence or air leak, requiring immediate intervention to prevent complications. Oxygen saturation of 94% is acceptable and does not require immediate intervention. Crepitus around the insertion site may be a normal finding after chest tube placement and does not necessarily indicate a complication. Drainage of 50 ml per hour is within the expected range for a chest tube and does not require immediate intervention.

2. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which laboratory value is most concerning?

• A. Serum sodium of 135 mEq/L
• B. Serum potassium of 4.0 mEq/L
• C. Serum bicarbonate of 18 mEq/L
• D. Serum glucose of 300 mg/dL

Correct answer: C

Rationale: A serum bicarbonate level of 18 mEq/L is most concerning in a client with COPD as it indicates metabolic acidosis, requiring immediate intervention. In COPD, patients often retain carbon dioxide, leading to respiratory acidosis. A low serum bicarbonate level suggests that the body is compensating for this respiratory acidosis by increasing bicarbonate levels to maintain balance. Therefore, a low serum bicarbonate level in this scenario is alarming. Choices A, B, and D are within normal ranges and not directly related to the acid-base imbalance seen in COPD.

3. A client with chronic kidney disease (CKD) is admitted with hyperkalemia. Which laboratory value is most concerning?

• A. Serum potassium of 6.5 mEq/L
• B. Serum sodium of 135 mEq/L
• C. Serum creatinine of 2.0 mg/dl
• D. Blood glucose of 150 mg/dl

Correct answer: A

Rationale: A serum potassium level of 6.5 mEq/L is concerning in a client with CKD as it indicates hyperkalemia, which requires immediate intervention to prevent cardiac complications. Hyperkalemia can lead to life-threatening arrhythmias, particularly in patients with impaired kidney function. Serum sodium, creatinine, and blood glucose levels, while important, are not as acutely dangerous as severe hyperkalemia in this context.

4. The nurse is caring for a client with diabetic ketoacidosis (DKA). Which intervention is most important?

• A. Administer insulin as prescribed.
• B. Monitor the client's urine output.
• C. Assess the client's level of consciousness.
• D. Obtain an arterial blood gas (ABG) sample.

Correct answer: A

Rationale: Administering insulin is the most crucial intervention in managing diabetic ketoacidosis. Insulin helps reduce blood glucose levels and correct metabolic acidosis, which are the primary issues in DKA. Monitoring urine output (Choice B) is important but not as critical as administering insulin. Assessing the client's level of consciousness (Choice C) is essential but does not directly address the underlying cause of DKA. Obtaining an arterial blood gas sample (Choice D) can provide valuable information but is not as urgent as administering insulin to address the immediate metabolic imbalance.

5. During the initial visit to a client with MS who is bed-bound and lifted by a hoist, which intervention is most important for the nurse to implement?

• A. Determine how the client is cared for when the caregiver is not present.
• B. Develop a client needs assessment and review it with the caregiver.
• C. Evaluate the caregiver's ability to care for the client's needs.
• D. Review with the caregiver the interventions provided each day.

Correct answer: A

Rationale: During the initial visit, the most crucial intervention for the nurse is to determine how the client is cared for when the caregiver is not present. This is essential to ensure the client's safety and well-being, especially during times when the caregiver is not available. Option B is not the most important as it focuses on assessment rather than immediate safety concerns. Option C, while important, is secondary to ensuring continuous care. Option D is less critical during the initial visit compared to ensuring care continuity in the caregiver's absence.

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