Nursing Elites

1. A client with chronic kidney disease (CKD) is experiencing nausea, vomiting, visual changes, and anorexia. Which action by the nurse is best?

• A. Check the client’s digoxin (Lanoxin) level.
• B. Administer an anti-nausea medication.
• C. Ask if the client can eat crackers.
• D. Refer the client to a gastrointestinal specialist.

Correct answer: A

Rationale: In a client with chronic kidney disease experiencing symptoms like nausea, vomiting, visual changes, and anorexia, it is crucial for the nurse to suspect digoxin (Lanoxin) toxicity. These symptoms are indicative of digoxin toxicity. Therefore, the best action for the nurse to take is to check the client's digoxin level. Administering anti-nausea medication, asking about eating crackers, and referring to a gastrointestinal specialist may help with symptom management but do not address the underlying cause of the symptoms, which is digoxin toxicity in this case.

2. After a session of hemodialysis, the nurse should monitor the client for which of the following complications of hemodialysis?

• A. Hyperkalemia.
• B. Hypotension.
• C. Infection.
• D. Fever.

Correct answer: B

Rationale: The correct answer is 'B: Hypotension.' Hypotension is a common complication of hemodialysis because fluid removal during the process can lead to a drop in blood pressure. The nurse should closely monitor the client for signs of hypotension such as dizziness, lightheadedness, or a decrease in blood pressure readings. Choice 'A: Hyperkalemia' is incorrect because hemodialysis actually helps lower potassium levels by removing excess potassium from the blood. Choice 'C: Infection' is incorrect as it is not a direct complication of hemodialysis but rather a risk associated with invasive procedures. Choice 'D: Fever' is incorrect as fever is not a typical immediate post-hemodialysis complication unless an underlying infection is present.

3. A client is recovering after a nephrostomy tube was placed 6 hours ago. The nurse notes drainage in the tube has decreased from 40 mL/hr to 12 mL over the last hour. Which action should the nurse take?

• A. Document the finding in the client’s record.
• B. Evaluate the tube as working in the hand-off report.
• C. Clamp the tube in preparation for removing it.
• D. Assess the client’s abdomen and vital signs.

Correct answer: D

Rationale: The correct action for the nurse to take in this situation is to assess the client’s abdomen and vital signs. The nephrostomy tube should have a consistent amount of drainage, and a decrease may indicate obstruction. Before notifying the provider, the nurse must assess the client for pain, distention, and changes in vital signs. This assessment is crucial to gather essential information to report accurately. Documenting the finding without further assessment may delay necessary intervention. Evaluating the tube as working in the hand-off report or clamping the tube prematurely are not appropriate actions and could lead to complications if there is an obstruction.

4. The nurse is preparing to give a dose of a cephalosporin medication to a patient who has been receiving the antibiotic for 2 weeks. The nurse notes ulcers on the patient’s tongue and buccal mucosa. Which action will the nurse take?

• A. Hold the drug and notify the provider.
• B. Obtain an order to culture the oral lesions.
• C. Gather emergency equipment to prepare for anaphylaxis.
• D. Report a possible superinfection side effect of the cephalosporin.

Correct answer: D

Rationale: The nurse should report a possible superinfection side effect of the cephalosporin to the physician as the patient's symptoms may indicate a superinfection that requires treatment. Holding the drug is not necessary unless directed by the provider. Culturing the lesions is not indicated for this situation. There is no evidence to suggest impending anaphylaxis based on the patient's symptoms.

5. Which of the following interventions is most appropriate for a patient with acute pancreatitis?

• A. Administering oral fluids.
• B. Administering IV fluids.
• C. Administering analgesics.
• D. Encouraging the patient to ambulate.

Correct answer: B

Rationale: The most appropriate intervention for a patient with acute pancreatitis is administering IV fluids. IV fluid administration is crucial in managing acute pancreatitis as it helps maintain hydration, correct electrolyte imbalances, and prevent shock. Administering oral fluids (Choice A) may not be sufficient to address the fluid loss and maintain hydration in these patients. While analgesics (Choice C) are important for pain management in pancreatitis, addressing hydration and shock prevention takes precedence. Encouraging the patient to ambulate (Choice D) may be beneficial in some cases for preventing complications like deep vein thrombosis, but it is not the primary intervention needed in the acute phase of pancreatitis.

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