Nursing Elites

1. After receiving hemodialysis, what is the nurse's priority assessment for a client with chronic kidney disease?

• A. Monitor the client's potassium level.
• B. Assess the client's blood pressure.
• C. Check the client's hemoglobin and hematocrit levels.
• D. Monitor for signs of infection.

Correct answer: A

Rationale: The correct answer is to monitor the client's potassium level. During hemodialysis, there is a risk of potassium shifting, which can lead to life-threatening arrhythmias if not properly managed. Assessing the potassium level is crucial to prevent complications. While assessing blood pressure, checking hemoglobin and hematocrit levels, and monitoring for signs of infection are important aspects of care for a client with chronic kidney disease, monitoring potassium levels takes precedence due to its immediate life-threatening potential post-dialysis.

2. An older client with chronic emphysema is admitted to the emergency room with acute weakness, palpitations, and vomiting. Which information is most important for the nurse to obtain during the initial interview?

• A. Recent compliance with prescribed medications.
• B. Sleep patterns during the previous few weeks.
• C. History of smoking over the past 6 months.
• D. Activity level prior to the onset of symptoms.

Correct answer: A

Rationale: The correct answer is A. In this scenario, the most critical information for the nurse to obtain during the initial interview is the recent compliance with prescribed medications. This is crucial to understand the client's baseline condition and management of chronic emphysema. Monitoring medication adherence can provide insights into potential exacerbating factors that may have led to the current acute symptoms. Choices B, C, and D are not as crucial in this situation. Sleep patterns, smoking history, and activity levels are important aspects of the client's overall health but do not take precedence over medication compliance when addressing acute symptoms in a client with chronic emphysema.

3. A client with tuberculosis is prescribed rifampin. What side effect should the nurse inform the client about?

• A. Report orange-colored urine as a sign of kidney dysfunction.
• B. Expect red-orange discoloration of urine as a harmless side effect.
• C. Monitor for signs of liver toxicity.
• D. Call the healthcare provider if vision changes occur.

Correct answer: B

Rationale: The correct answer is B. Rifampin can cause red-orange discoloration of bodily fluids, including urine, saliva, and tears. This is a harmless side effect, but clients should be informed beforehand to prevent alarm. Choice A is incorrect as orange-colored urine is not a sign of kidney dysfunction related to rifampin. Choice C is incorrect because rifampin is more commonly associated with liver toxicity rather than kidney dysfunction. Choice D is incorrect as vision changes are not a typical side effect of rifampin.

4. A male client admitted for schizophrenia is noted to be diaphoretic and pacing the hallway. What is the most important intervention?

• A. Take the client's temperature and blood pressure.
• B. Encourage the client to rest.
• C. Plan an activity involving physical exercise.
• D. Carefully observe the client throughout the shift.

Correct answer: D

Rationale: In this scenario, the most important intervention for a male client with schizophrenia who is diaphoretic and pacing the hallway is to carefully observe the client throughout the shift. Diaphoresis and pacing can be indicators of agitation or distress in clients with schizophrenia. Careful observation is crucial to monitor the client's safety, assess for any potential escalation of symptoms, and provide timely intervention if needed. Taking the client's temperature and blood pressure (Choice A) may not address the immediate need for safety and observation. Encouraging the client to rest (Choice B) may not be effective if the client is agitated. Planning an activity involving physical exercise (Choice C) could potentially exacerbate the situation rather than addressing the immediate need for observation and safety.

5. A client with dysphagia is having difficulty swallowing medications. What is the nurse's best intervention?

• A. Crush the medications and mix them with applesauce.
• B. Encourage the client to drink water with each dose.
• C. Consult with the healthcare provider about switching to liquid medications.
• D. Offer the client soft foods to reduce difficulty swallowing.

Correct answer: C

Rationale: The best intervention for a client with dysphagia experiencing difficulty swallowing medications is to consult with the healthcare provider about switching to liquid medications. Liquid medications are often easier to swallow and can reduce the risk of choking and aspiration in clients with dysphagia. Crushing medications can alter their effectiveness, encouraging the client to drink water may not be sufficient, and offering soft foods is not directly related to improving medication swallowing.

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