Nursing Elites

1. What is the primary concern in a patient with a low CD4 T-cell count in HIV?

• A. Increased risk of infection
• B. Increased risk of bleeding
• C. Decreased immunity leading to opportunistic infections
• D. Increased risk of cardiac complications

Correct answer: A

Rationale: The correct answer is A: Increased risk of infection. In HIV patients with a low CD4 T-cell count, the primary concern is the increased susceptibility to infections due to compromised immunity. This compromised immune system can lead to various infections, making infection control crucial. Choice B, increased risk of bleeding, is not directly associated with a low CD4 count in HIV. Option C, decreased immunity leading to opportunistic infections, conveys a similar concern as the correct answer but lacks specificity. Choice D, increased risk of cardiac complications, is not typically the primary concern in HIV patients with a low CD4 count, as infections and opportunistic diseases pose more immediate threats to health.

2. A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should indicate to the nurse the need for immediate intervention?

• A. Axillary temperature 37.2°C (99°F)
• B. Apical pulse 100/min
• C. Respiratory rate 30/min
• D. Blood pressure 140/84 mm Hg

Correct answer: C

Rationale: The correct answer is C. The nurse should prioritize airway and breathing in a client with a traumatic brain injury. An increased respiratory rate may indicate CO2 retention, which could lead to increased intracranial pressure. Choice A, axillary temperature 37.2°C (99°F), is within normal range and does not indicate an immediate need for intervention. Choice B, apical pulse 100/min, is slightly elevated but not as critical as respiratory distress in this scenario. Choice D, blood pressure 140/84 mm Hg, is also within normal limits and does not require immediate intervention compared to the respiratory rate.

3. What are the expected ECG findings in hypokalemia?

• A. Flattened T waves
• B. Prominent U waves
• C. Elevated ST segments
• D. Wide QRS complex

Correct answer: A

Rationale: Flattened T waves are the classic ECG finding in hypokalemia. Hypokalemia primarily affects the repolarization phase of the cardiac action potential, leading to T wave abnormalities. While prominent U waves are typically associated with hypokalemia as well, flattened T waves are the most specific and sensitive ECG abnormality seen in hypokalemia. Elevated ST segments and wide QRS complexes are not typically seen in hypokalemia and are more indicative of other electrolyte imbalances or cardiac conditions.

4. 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.

5. What is the initial nursing action for a patient with a chest tube found to have an air leak?

• A. Check the tube connections
• B. Replace the chest tube
• C. Remove and reinsert the chest tube
• D. Document the incident

Correct answer: A

Rationale: When a patient with a chest tube is found to have an air leak, the priority action for the nurse is to check the tube connections. This step helps identify the source of the air leak, which can be caused by loose or disconnected tube connections. Once the source of the leak is identified and addressed, further interventions may be necessary. Replacing or removing and reinserting the chest tube should not be the initial response unless there are specific indications for these actions. Documenting the incident is important but comes after addressing the immediate concern of the air leak.

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