Nursing Elites

1. Upon admission, a 77-year-old female client presents with confusion, loss of appetite, nausea, vomiting, and headache, with a pulse rate of 43 beats per minute. Which question should the nurse prioritize asking the client or her family?

• A. Does the client have her own teeth or dentures?
• B. Does the client take aspirin, and if so, what is the dosage?
• C. Does the client take nitroglycerin?
• D. Does the client take digitalis?

Correct answer: D

Rationale: The correct answer is D. The client's symptoms suggest digitalis toxicity, a potentially life-threatening condition that requires immediate attention. Digitalis toxicity can present with symptoms such as anorexia, nausea, vomiting, headache, and bradycardia (low pulse rate). Given the client's presentation, it is crucial to assess for digitalis use as elderly individuals are more susceptible to this type of intoxication. Choices A, B, and C are important aspects to consider during the assessment, but in this scenario, the priority lies in identifying and addressing the potential digitalis toxicity due to the severity of symptoms and the need for prompt intervention.

2. A client who was involved in a motor vehicle collision is admitted with a fractured left femur that is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). The nurse determines that the client's distal pulses are diminished in the left foot. Which intervention should the nurse implement?

• A. Verify pedal pulses using a Doppler pulse device
• B. Evaluate the application of the splint to the left leg
• C. Offer ice chips and clear oral liquids
• D. Monitor the left leg for pain, pallor, paresthesia, paralysis, pressure

Correct answer: B

Rationale: Evaluating the application of the splint is the priority as it ensures it is not too tight, which could impair circulation and exacerbate the diminished pulses. Verifying pedal pulses with a Doppler pulse device may be indicated but does not directly address the immediate concern of proper splint application. Offering ice chips and clear oral liquids would not address the issue of diminished distal pulses. Monitoring the left leg for pain, pallor, paresthesia, paralysis, and pressure is important but would not directly address the cause of the diminished pulses in this scenario.

3. A client expresses difficulty voiding in public places. How should the nurse respond?

• A. Offer to turn on the faucet in the bathroom to help stimulate urination.
• B. Suggest a prescription for a diuretic to increase urine output.
• C. Propose moving to a room with a private bathroom to enhance comfort.
• D. Close the curtain to provide maximum privacy.

Correct answer: D

Rationale: The nurse should prioritize the client's privacy when addressing issues related to voiding discomfort in public places. Closing the curtain in the current room would offer immediate privacy and support the client's needs. Turning on the faucet is not an evidence-based intervention for voiding difficulties. Prescribing a diuretic is not appropriate without further assessment. While moving to a room with a private bathroom might be ideal, it may not be immediately feasible, making ensuring privacy in the current setting the most appropriate action.

4. After educating a client with hypertension secondary to renal disease, the nurse assesses the client’s understanding. Which statement made by the client indicates a need for additional teaching?

• A. I can prevent more damage to my kidneys by managing my blood pressure.
• B. If I have increased urination at night, I need to drink less fluid during the day.
• C. I need to see the registered dietitian to discuss limiting my protein intake.
• D. It is important that I take my antihypertensive medications as directed.

Correct answer: B

Rationale: Choice B is incorrect because the client should not restrict fluids during the day due to increased urination at night. Clients with renal disease may be prescribed fluid restrictions, and they should be thoroughly assessed for potential dehydration. To decrease increased nocturnal voiding, clients should consume fluids earlier in the day. Choices A, C, and D are correct statements. Managing blood pressure is crucial to slow the progression of renal dysfunction. Limiting protein intake is important in renal disease management, and clients should be referred to a dietitian as needed. Taking antihypertensive medications as directed is essential for blood pressure control.

5. What is an ideal goal of treatment set by the nurse in the care plan for a client diagnosed with chronic kidney disease (CKD) to reduce the risk of pulmonary edema?

• A. Maintaining oxygen saturation above 92%
• B. Absence of crackles and wheezes in lung sounds
• C. Maintaining a balanced intake and output
• D. Absence of shortness of breath at rest

Correct answer: C

Rationale: The ideal goal of treatment for a client with chronic kidney disease (CKD) to reduce the risk of pulmonary edema is to maintain a balanced intake and output. This helps in achieving optimal fluid balance, enabling the heart to eject blood effectively without increasing pressure in the left ventricle and pulmonary vessels. While maintaining oxygen saturation above 92% is important for adequate tissue oxygenation, the primary focus in this scenario is fluid balance. Absence of crackles and wheezes in lung sounds is important to assess for pulmonary status, but it is not the primary goal to prevent pulmonary edema specifically. Similarly, absence of shortness of breath at rest is a relevant goal, but the emphasis in CKD management is on fluid balance to prevent pulmonary complications.

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