Nokea
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.
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The wound irrigation process cleanses the wound and:
- A. Reduces the potential pain in the wound region or area.
- B. Stops the spread of infection by creating a 'clean' area.
- C. Pushes extravasated blood from a hematoma into nearby healthy tissue.
- D. Allows for the introduction of medications in solution form.
Correct Answer: D
Rationale: The correct answer is D because wound irrigation allows for the introduction of medications in solution form to the wound site. Choice A is incorrect because while wound irrigation can help with pain management indirectly by promoting healing, its primary purpose is not to reduce pain directly. Choice B is incorrect as wound irrigation primarily aims to cleanse the wound and remove contaminants rather than creating a 'clean' area to stop infection spread. Choice C is incorrect because wound irrigation does not involve pushing extravasated blood from a hematoma into nearby healthy tissue; its main goal is to cleanse the wound and promote healing.
A clinical instructor teaches a class for the public about diabetes mellitus. Which individual does the nurse assess as being at highest risk for developing diabetes?
- A. The 50-year-old client who does not engage in any physical exercise
- B. The 56-year-old client who drinks three glasses of wine daily
- C. The 42-year-old client who is 50 pounds overweight
- D. The 38-year-old client who smokes one pack of cigarettes daily
Correct Answer: C
Rationale: The 42-year-old client who is 50 pounds overweight is at the highest risk for developing diabetes. Excess weight is a significant risk factor for diabetes as it can lead to insulin resistance and metabolic abnormalities. Choices A, B, and D are also risk factors for diabetes, but being overweight has a stronger association with the development of the condition compared to lack of exercise, excessive alcohol consumption, or smoking.
Select the nursing theorist who is accurately paired with the theory or model of nursing that they are credited with.
- A. The Twelve Nursing Problems: Faye Glenn Abdullah
- B. The Nature of Nursing: Imogene King
- C. The Goal Attainment Theory: Virginia Henderson
- D. The Interpersonal Relations Model: Hildegard Peplau
Correct Answer: D
Rationale: The correct answer is D. Hildegard Peplau is credited with the Interpersonal Relations Model in nursing. Faye Glenn Abdullah is associated with the Developmental Theory of Nursing. Imogene King developed the Theory of Goal Attainment. Virginia Henderson is known for the Definition of Nursing. Therefore, among the given options, only Hildegard Peplau is correctly paired with the Interpersonal Relations Model.
You are caring for a patient with multiple trauma. Of all of these injuries and conditions, which is the most serious?
- A. A deviated trachea
- B. Gross deformity of a lower extremity
- C. Hematuria
- D. Decreased bowel sounds
Correct Answer: A
Rationale: A deviated trachea is the most serious condition among the choices provided. It can indicate a tension pneumothorax, which is a life-threatening emergency requiring immediate intervention to prevent respiratory compromise. Choice B, a gross deformity of a lower extremity, while significant, is not as immediately life-threatening as a deviated trachea. Choice C, hematuria, may indicate kidney injury but is not as acutely life-threatening as a deviated trachea. Choice D, decreased bowel sounds, could indicate abdominal issues, but it is not as urgent or immediately life-threatening as a deviated trachea.
A nurse in a clinic is reviewing laboratory reports for a group of clients. Which of the following diseases should the nurse report to the state health department?
- A. Pertussis
- B. Group B streptococcal disease
- C. Respiratory syncytial virus
- D. Rotavirus
Correct Answer: A
Rationale: Pertussis is the correct answer because it is a reportable disease that healthcare providers are required by law to report to public health authorities. This infectious disease poses a significant public health risk and needs to be monitored closely to prevent outbreaks and implement control measures. Group B streptococcal disease, Respiratory syncytial virus, and Rotavirus are important conditions but are not typically reportable to the state health department. These diseases may require specific precautions in healthcare settings, but they do not fall under mandatory reporting requirements.