Nursing Elites

1. Which healthcare-associated infection poses the greatest risk for patients?

• A. Pneumonia
• B. Catheter-related infections
• C. Intravenous line infections
• D. C. difficile

Correct answer: B

Rationale: Catheter-related infections pose the greatest risk for patients in healthcare settings. Catheters are invasive devices that can introduce pathogens directly into the bloodstream, leading to severe infections. Pneumonia, intravenous line infections, and C. difficile infections are serious concerns as well, but catheter-related infections are particularly risky due to the direct access they provide for pathogens to enter the body.

2. A nurse caring for a group of clients reviews the electrolyte laboratory results and notes a sodium level of 130 mEq/L on one client's laboratory report. The nurse understands that which client is at highest risk for the development of a sodium value at this level?

• A. The client with renal failure
• B. The client who is taking diuretics
• C. The client with hyperaldosteronism
• D. The client who is taking corticosteroids

Correct answer: B

Rationale: The correct answer is B. Clients taking diuretics are at risk for hyponatremia due to excessive sodium loss. In this scenario, a sodium level of 130 mEq/L indicates hyponatremia, which is commonly associated with diuretic use. Options A, C, and D are not the highest risk factors for developing low sodium levels in this context. Renal failure, hyperaldosteronism, and corticosteroid use are not directly linked to sodium loss as seen with diuretics.

3. A nurse is assessing a client who is postoperative following a left leg below-the-knee amputation. Which of the following client statements indicates the potential need for a referral to an occupational therapist?

• A. I hope I can adjust to using crutches while I am recovering.
• B. I am worried about taking care of my toddler at home.
• C. I just don't think I can handle looking at my leg.
• D. I am not sure how I will pay for all the therapy I will need.

Correct answer: A

Rationale: The client's statement about adjusting to using crutches while recovering suggests a potential need for occupational therapy referral. Occupational therapists assist individuals in regaining independence in activities of daily living, including mobility aids and adaptations. Choices B, C, and D are more indicative of emotional or financial concerns and may require referrals to other healthcare professionals like counselors or financial advisors, rather than occupational therapists.

4. 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.

5. Serge, who has diabetes mellitus, is taking oral agents and is scheduled for a diagnostic test that requires him to be NPO. What is the best plan of action for the nurse regarding Serge's oral medications?

• A. Administer the oral agents immediately after the test.
• B. Notify the diagnostic department and request orders.
• C. Notify the physician and request orders.
• D. Administer the oral agents with a sip of water before the test.

Correct answer: C

Rationale: The best plan of action for the nurse is to notify the physician and request orders regarding Serge's oral medications. By involving the physician, the nurse ensures that appropriate instructions are obtained, considering Serge's medical condition and the need for NPO status for the diagnostic test. Administering the medications without medical guidance (choice A) can be risky, as it may affect the test results. Notifying the diagnostic department (choice B) is not the most direct and appropriate action; the physician is the primary healthcare provider responsible for medication orders. Administering the medications with water before the test (choice D) is not advisable when the patient is supposed to be NPO, as it can interfere with the test requirements.

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