Nursing Elites

1. After hemodialysis, a client with a history of chronic renal failure has just returned to the unit. What is the most important assessment for the nurse to make?

• A. Auscultate the client's lung sounds.
• B. Assess the client's blood pressure.
• C. Monitor the client's weight.
• D. Check the client's fistula for bruit and thrill.

Correct answer: D

Rationale: The most crucial assessment for the nurse to make after hemodialysis in a client with chronic renal failure is to check the client's fistula for bruit and thrill (D). This assessment is essential to ensure the patency of the fistula and adequate blood flow. Auscultating lung sounds (A), assessing blood pressure (B), and monitoring weight (C) are important assessments but are secondary to evaluating the fistula. Checking the fistula is vital as it directly impacts the effectiveness of the client's dialysis treatment and the patency of the vascular access, ensuring successful dialysis sessions.

2. The UAP is positioning a newly admitted client with a seizure disorder in a supine position. The UAP is placing soft pillows along the side rails. What action should the nurse take?

• A. Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows
• B. Ensure that the UAP has placed pillows effectively to protect the client
• C. Ask the UAP to use some pillows to prop the client in a side-lying position
• D. Assume responsibility for placing the pillows while the UAP completes another task

Correct answer: A

Rationale: To prevent the risk of suffocation, soft blankets are preferred over pillows for padding side rails in clients with seizure disorders. Pillows can pose a suffocation hazard, especially during a seizure episode when the client's movements may be uncontrolled. Instructing the UAP to use soft blankets instead of pillows is crucial for ensuring the client's safety. Choice B is incorrect because pillows can be hazardous during a seizure. Choice C is incorrect as side-lying position may not be appropriate for a client with a seizure disorder. Choice D is incorrect as it does not address the safety concern related to using pillows.

3. The healthcare provider is caring for a client who is experiencing fluid volume deficit (dehydration). Which intervention should the healthcare provider implement to assess the effectiveness of fluid replacement therapy?

• A. Monitor daily weights
• B. Assess skin turgor
• C. Evaluate blood pressure trends
• D. Check urine specific gravity

Correct answer: A

Rationale: Monitoring daily weights is an accurate method to assess the effectiveness of fluid replacement therapy because changes in weight reflect changes in fluid balance. Fluid volume deficit can be objectively evaluated by monitoring daily weights as it provides a more precise measurement of fluid status over time. Assessing skin turgor (choice B) is subjective and may not provide as accurate or measurable data as monitoring daily weights. Evaluating blood pressure trends (choice C) can give information about circulatory status but may not directly reflect fluid volume status. Checking urine specific gravity (choice D) can indicate the concentration of urine but does not provide a comprehensive assessment of overall fluid balance like monitoring daily weights does.

4. When assisting an older adult client in preparing to take a tub bath, which nursing action is most important?

• A. Check the bath water temperature.
• B. Shut the bathroom door.
• C. Ensure that the client has voided.
• D. Provide extra towels.

Correct answer: A

Rationale: The most crucial nursing action when assisting an older adult client with a tub bath is to check the bath water temperature. This step is essential to prevent burns from hot water or chilling from water that is too cold. Ensuring the water temperature is safe is a critical aspect of promoting the client's safety and comfort during the bathing process.

5. A CVA (stroke) patient goes into respiratory distress and is placed on a ventilator. The client’s daughter arrives with a durable power of attorney and a living will that indicates there should be no extraordinary life-saving measures. What action should the nurse take?

• A. Refer to the risk manager
• B. Notify the healthcare provider
• C. Discontinue the ventilator
• D. Review the medical record

Correct answer: B

Rationale: In this situation, the nurse should notify the healthcare provider. The healthcare provider needs to be informed to review the legal documents provided by the patient's daughter, such as the durable power of attorney and living will, which specify the patient's wishes regarding life-saving measures. The healthcare provider will be responsible for making the appropriate decision based on the legal documents and the patient's current condition. Referring to the risk manager (choice A) is not necessary as the issue at hand pertains to the patient's medical care. Discontinuing the ventilator (choice C) without healthcare provider input could go against the patient's wishes and legal documents. Reviewing the medical record (choice D) may not provide immediate guidance on the current situation and the patient's preferences regarding life-saving measures.

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