Nursing Elites

1. What are the expected changes on an ECG for a patient with hypokalemia?

• A. Flattened T waves
• B. Prominent U waves
• C. ST elevation
• D. Wide QRS complexes

Correct answer: A

Rationale: Flattened T waves are an early sign of hypokalemia on an ECG. Hypokalemia primarily manifests as flattened T waves on an ECG. While prominent U waves can be seen in hypokalemia, they are not as specific as flattened T waves. ST elevation is more commonly associated with conditions like myocardial infarction rather than hypokalemia. Wide QRS complexes are typically not a feature of hypokalemia on an ECG.

2. What is the priority intervention when continuous bubbling is observed in the water seal chamber of a chest tube?

• A. Check for an air leak
• B. Continue monitoring as it is not normal
• C. Replace the chest tube system
• D. Tighten the tube connections

Correct answer: A

Rationale: The correct answer is to 'Check for an air leak.' Continuous bubbling in the water seal chamber of a chest tube indicates an air leak, which can compromise the effectiveness of the chest tube in re-expanding the lung. Checking for an air leak is crucial to prevent respiratory complications. Choice B is incorrect because continuous bubbling is not normal and requires immediate intervention to address the air leak. Choice C is incorrect as replacing the entire chest tube system is not the initial priority when an air leak is suspected. Choice D is incorrect because tightening tube connections may not address the underlying issue of an air leak and should not be the initial action taken in this situation.

3. When caring for a patient with hypokalemia, what should the nurse monitor for?

• A. Monitor for muscle weakness
• B. Check for cardiac dysrhythmias
• C. Monitor for bradycardia
• D. Monitor for seizures

Correct answer: A

Rationale: Corrected Answer: Muscle weakness is a common sign of hypokalemia. The nurse should monitor for muscle weakness as potassium plays a crucial role in muscle function. Choices B, C, and D are incorrect because although hypokalemia can lead to cardiac dysrhythmias, bradycardia, and even seizures in severe cases, muscle weakness is a more common and specific sign directly related to potassium levels.

4. A nurse misreads a glucose level and administers insulin for a blood glucose of 210 mg/dL instead of 120 mg/dL. What is the priority intervention?

• A. Monitor for hypoglycemia
• B. Monitor for hyperkalemia
• C. Administer glucose IV
• D. Document the incident

Correct answer: A

Rationale: The correct answer is to monitor for hypoglycemia. In this scenario, the nurse administered insulin based on a misread glucose level, which could lead to hypoglycemia due to excessive insulin action lowering blood glucose levels. Monitoring for hypoglycemia allows for prompt recognition and intervention if blood glucose levels drop significantly. Choice B, monitoring for hyperkalemia, is incorrect as administering insulin would not cause hyperkalemia. Choice C, administering glucose IV, is not appropriate at this time since the patient's blood glucose level is already elevated. Choice D, documenting the incident, is important but not the priority at this moment when patient safety is at risk due to potential hypoglycemia.

5. A patient reports abdominal cramping after enema administration. What action should the nurse take to relieve the discomfort?

• A. Lower the height of the solution container
• B. Increase the flow of enema solution
• C. Remove the enema tubing
• D. Stop the procedure

Correct answer: A

Rationale: The correct action to relieve abdominal cramping after enema administration is to lower the height of the solution container. This adjustment slows down the flow rate of the enema solution, which can help reduce discomfort by decreasing the pressure on the patient's abdomen. Increasing the flow of the enema solution (Choice B) would exacerbate the cramping by introducing more solution quickly. Removing the enema tubing (Choice C) is not necessary to address the cramping, and stopping the procedure (Choice D) may not be needed if adjusting the height of the solution container can resolve the issue.

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