Nursing Elites

1. For a client with chronic kidney disease having a hemoglobin level of 8.0 g/dL, which intervention should the nurse perform first?

• A. Administer erythropoietin as ordered
• B. Monitor the client's blood pressure
• C. Monitor the client's oxygen saturation level
• D. Assess the client for signs of fatigue

Correct answer: A

Rationale: Administering erythropoietin is the priority intervention for a client with chronic kidney disease and a low hemoglobin level. Erythropoietin stimulates red blood cell production, helping to manage anemia in these clients. Monitoring blood pressure, oxygen saturation level, and assessing for signs of fatigue are important aspects of care but addressing the anemia by administering erythropoietin takes precedence to improve oxygen-carrying capacity and overall well-being.

2. The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority?

• A. Assess nail beds for color and refill
• B. Assess for postoperative arrhythmias
• C. Auscultate for pulmonary congestion
• D. Monitor equality of peripheral pulses

Correct answer: B

Rationale: Postoperative arrhythmias are a common and potentially serious complication after cardiac surgery, making them a priority to monitor. Assessing for postoperative arrhythmias takes precedence over other assessments like checking nail beds for color and refill, auscultating for pulmonary congestion, or monitoring peripheral pulses as arrhythmias can have immediate and severe implications for the child's health.

3. A client in a long term care facility complains of pain. The nurse collects data about the client's pain. The first step in pain assessment is for the nurse to

• A. have the client identify coping methods
• B. get the description of the location and intensity of the pain
• C. accept the client's report of pain
• D. determine the client's status of pain

Correct answer: B

Rationale: The correct answer is B: 'get the description of the location and intensity of the pain.' When a client complains of pain, the initial step in pain assessment is to gather information about the location and intensity of the pain. This helps the nurse understand the nature of the pain and lays the groundwork for further assessment and management. Choice A is incorrect because identifying coping methods comes later in the assessment process. Choice C is incorrect as accepting the client's report of pain is important, but not the first step. Choice D is incorrect as determining the client's pain status also comes after gathering information about the pain.

4. Which client calling the community health clinic would the nurse ask to come in that day to be seen by the health care provider?

• A. I started my period, and now my urine has turned bright red.
• B. I am a diabetic, and today I have been going to the bathroom every hour.
• C. I was started on medicine yesterday for a urinary infection. Now my lower belly hurts when I go to the bathroom.
• D. I went to the bathroom, and my urine looked very red, and it didn't hurt when I went.

Correct answer: D

Rationale: The correct answer is D because bright red urine without pain suggests possible hematuria, which is a concerning symptom that requires immediate medical evaluation. Option A mentions bright red urine but also relates it to starting a period, which is less likely to be an urgent issue. Option B describes increased urination, which may indicate hyperglycemia but doesn't require immediate evaluation. Option C presents symptoms more related to a urinary tract infection that may not require urgent attention.

5. A client with a history of coronary artery disease is admitted with chest pain. Which of these findings would be most concerning to the nurse?

• A. Blood pressure of 130/80 mm Hg
• B. Respiratory rate of 20 breaths per minute
• C. Heart rate of 72 beats per minute
• D. Temperature of 98.6 degrees Fahrenheit

Correct answer: B

Rationale: The correct answer is B. A respiratory rate of 20 breaths per minute may indicate respiratory distress in a client with chest pain. In a client with a history of coronary artery disease presenting with chest pain, signs of respiratory distress can be an alarming finding. Blood pressure within the normal range (130/80 mm Hg), heart rate of 72 beats per minute, and a temperature of 98.6 degrees Fahrenheit are generally considered within normal limits and may not be as concerning in this context.

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