Nursing Elites

1. A client reports for a scheduled electroencephalogram (EEG). Which statement by the client indicates a need for additional preparation for the test?

• A. I didn’t shampoo my hair.
• B. I ate breakfast this morning.
• C. I didn’t take my anticonvulsant today.
• D. It was hard not to drink coffee this morning, but I knew that I couldn’t, so I didn’t.

Correct answer: A

Rationale: The correct answer is A. For an EEG, it is essential that the client's hair is clean, without any products like hairspray or gel, to ensure good electrode contact with the scalp. Choice B is not a concern as having breakfast is allowed before the test. Choice C, not taking an anticonvulsant, might be required for certain types of EEGs to capture accurate brain activity. Choice D, not drinking coffee, is not a specific requirement for an EEG preparation.

2. A client with a history of lung disease is at risk for respiratory acidosis. For which of the following signs and symptoms does the nurse assess this client?

• A. Disorientation and dyspnea
• B. Drowsiness, headache, and tachypnea
• C. Tachypnea, dizziness, and paresthesias
• D. Dysrhythmias and decreased respiratory rate and depth

Correct answer: A

Rationale: The correct answer is A: Disorientation and dyspnea. In respiratory acidosis, the retention of carbon dioxide leads to an increase in carbonic acid, causing the pH of the blood to decrease. This can result in symptoms such as dyspnea (difficulty breathing) due to hypoxia and disorientation due to the effects of hypercapnia (elevated carbon dioxide levels) on the brain. Choice B is incorrect because while drowsiness and tachypnea can be present in respiratory acidosis, headache is not a common symptom. Choice C is incorrect because dizziness and paresthesias are not typical symptoms of respiratory acidosis. Choice D is incorrect because dysrhythmias and a decreased respiratory rate and depth are more commonly associated with respiratory alkalosis, not respiratory acidosis.

3. A client who has developed acute kidney injury (AKI) due to an aminoglycoside antibiotic has moved from the oliguric phase to the diuretic phase of AKI. Which parameters are most important for the nurse to plan to carefully monitor?

• A. Side effects of total parenteral nutrition (TPN) and Intralipids.
• B. Uremic irritation of mucous membranes and skin surfaces.
• C. Elevated creatinine and blood urea nitrogen (BUN).
• D. Hypovolemia and electrocardiographic (ECG) changes.

Correct answer: D

Rationale: During the diuretic phase of acute kidney injury (AKI), monitoring for hypovolemia and electrocardiographic (ECG) changes is crucial. Hypovolemia can occur due to the increased urine output in this phase, potentially leading to dehydration and electrolyte imbalances. Electrolyte imbalances can result in ECG changes, such as arrhythmias, which can be life-threatening. Therefore, careful monitoring of fluid status and ECG findings helps in preventing complications. Choices A, B, and C are not the most crucial parameters to monitor during the diuretic phase of AKI. Side effects of total parenteral nutrition (TPN) and Intralipids, uremic irritation of mucous membranes and skin surfaces, and elevated creatinine and blood urea nitrogen (BUN) are important considerations in other phases of AKI or in other conditions, but they are not the primary focus during the diuretic phase when hypovolemia and ECG changes take precedence.

4. A nurse assesses a client who is recovering from a radical nephrectomy for renal cell carcinoma. The nurse notes that the client’s blood pressure has decreased from 134/90 to 100/56 mm Hg and urine output is 20 mL for this past hour. Which action should the nurse take?

• A. Position the client to lay on the surgical incision.
• B. Measure the specific gravity of the client’s urine.
• C. Administer intravenous pain medications.
• D. Assess the rate and quality of the client’s pulse.

Correct answer: D

Rationale: The nurse should first fully assess the client for signs of volume depletion and shock, and then notify the provider. The radical nature of the surgery and the proximity of the surgery to the adrenal gland put the client at risk for hemorrhage and adrenal insufficiency. Hypotension is a clinical manifestation associated with both hemorrhage and adrenal insufficiency. Hypotension is particularly dangerous for the remaining kidney, which must receive adequate perfusion to function effectively. Re-positioning the client, measuring specific gravity, and administering pain medication would not provide data necessary to make an appropriate clinical decision, nor are they appropriate interventions at this time.

5. Which of the following is the best indicator of fluid balance in a patient with heart failure?

• A. Daily weight measurements.
• B. Monitoring intake and output.
• C. Assessing skin turgor.
• D. Checking for peripheral edema.

Correct answer: A

Rationale: Daily weight measurements are the best indicator of fluid balance in a patient with heart failure. Changes in weight reflect fluid retention or loss more accurately than other methods. Monitoring intake and output (choice B) is essential but may not provide a comprehensive picture of fluid status. Skin turgor (choice C) and checking for peripheral edema (choice D) are more indicative of dehydration and fluid overload, respectively, rather than overall fluid balance.

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