Nursing Elites

1. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which finding indicates the need for immediate intervention?

• A. Use of accessory muscles
• B. Oxygen saturation of 94%
• C. Carbon dioxide level of 45 mmHg
• D. Respiratory rate of 20 breaths per minute

Correct answer: C

Rationale: A carbon dioxide level of 45 mmHg is concerning in a client with COPD receiving supplemental oxygen, as it may indicate carbon dioxide retention and requires immediate intervention. Options A, B, and D are not the priority findings in this scenario. While the use of accessory muscles, an oxygen saturation of 94%, and a respiratory rate of 20 breaths per minute are important to monitor in a client with COPD, they do not indicate an immediate need for intervention like an elevated carbon dioxide level does.

2. A client with chronic kidney disease (CKD) is admitted with hyperkalemia. Which assessment finding is most concerning?

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

Correct answer: C

Rationale: The correct answer is C: Peaked T waves on the ECG. In hyperkalemia, elevated potassium levels can affect the heart's electrical activity, leading to changes on the ECG such as peaked T waves. This finding is concerning as it can progress to serious cardiac arrhythmias, including ventricular tachycardia and fibrillation. Bradycardia (choice A) and decreased deep tendon reflexes (choice D) are not typically associated with hyperkalemia. While muscle weakness (choice B) can occur in hyperkalemia due to its effect on neuromuscular function, the most concerning assessment finding indicating the need for immediate intervention in this scenario is peaked T waves on the ECG.

3. A confused, older client with Alzheimer's disease becomes incontinent of urine when attempting to find the bathroom. Which action should the nurse implement?

• A. Assist the client to a bedside commode every two hours
• B. Insert an indwelling catheter
• C. Use adult diapers to manage incontinence
• D. Restrict fluids in the evening

Correct answer: A

Rationale: The correct action for the nurse to implement is to assist the client to a bedside commode every two hours. This approach, known as scheduled toileting, is essential in managing incontinence in clients with cognitive impairments like Alzheimer's disease. By providing regular assistance to the client to use the commode, the nurse can help maintain continence and reduce accidents. Inserting an indwelling catheter (Choice B) should be avoided if possible to prevent the risk of urinary tract infections. Using adult diapers (Choice C) should be considered a last resort and not the initial intervention. Restricting fluids in the evening (Choice D) is not appropriate as it may lead to dehydration and other complications.

4. The nurse is assessing a client with left-sided heart failure. Which laboratory value is most concerning?

• A. Serum creatinine of 1.5 mg/dL
• B. Serum sodium of 136 mEq/L
• C. Serum potassium of 5.5 mEq/L
• D. Hemoglobin of 12 g/dL

Correct answer: C

Rationale: A serum potassium level of 5.5 mEq/L is most concerning in a client with left-sided heart failure as it indicates hyperkalemia, requiring immediate intervention. Hyperkalemia can lead to life-threatening cardiac arrhythmias, which can exacerbate heart failure. Serum creatinine of 1.5 mg/dL is slightly elevated but not as immediately concerning as hyperkalemia. Serum sodium of 136 mEq/L is within the normal range. Hemoglobin of 12 g/dL is also within the normal range and not directly related to the client's left-sided heart failure.

5. Following an open reduction of the tibia, the nurse notes bleeding on the client's cast. Which action should the nurse implement?

• A. Outline the area with ink and check it every 15 minutes to see if the area has increased
• B. Notify the healthcare provider immediately
• C. Apply a new cast to stop the bleeding
• D. Elevate the limb to reduce blood flow

Correct answer: A

Rationale: After an open reduction of the tibia, bleeding on the cast can be a concern. Outlining the area with ink and monitoring it every 15 minutes is the appropriate action to assess if the bleeding is worsening, indicating the need for further intervention. This action allows for close observation without disturbing the cast. Choice B is incorrect because while notifying the healthcare provider is important, immediate action is not always necessary if the bleeding is not severe. Choice C is incorrect because applying a new cast is not the standard intervention for bleeding on a cast. Choice D is incorrect because elevating the limb may not address the underlying cause of bleeding and may not be the most appropriate action at this time.

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