Nursing Elites

1. A client with chronic kidney disease is receiving peritoneal dialysis. Which assessment finding should the nurse report to the healthcare provider immediately?

• A. The client's weight increases by 1 kg in 24 hours.
• B. The client's peritoneal effluent is cloudy.
• C. The client's blood pressure is 140/90 mm Hg.
• D. The client's peritoneal effluent is clear and pale yellow.

Correct answer: B

Rationale: Cloudy peritoneal effluent (B) is a sign of infection and should be reported to the healthcare provider immediately. It indicates the presence of peritonitis, a severe complication that requires prompt intervention. Weight gain (A) may indicate fluid overload but is not as urgent as a potential infection. Elevated blood pressure (C) is a common finding in clients with kidney disease and needs monitoring but does not require immediate reporting. Clear and pale yellow effluent (D) is a normal finding and does not raise immediate concerns.

2. The nurse is providing discharge teaching to a client with a new prescription for warfarin (Coumadin). Which dietary instruction should the nurse include?

• A. Avoid foods high in vitamin K
• B. Increase intake of leafy green vegetables
• C. Consume a consistent amount of foods high in potassium
• D. Limit intake of high-protein foods

Correct answer: A

Rationale: The correct dietary instruction for a client taking warfarin is to avoid foods high in vitamin K. Warfarin is an anticoagulant that works by inhibiting vitamin K-dependent clotting factors. Consuming foods high in vitamin K, such as leafy green vegetables, can antagonize the effects of warfarin, potentially leading to treatment inefficacy or fluctuations in anticoagulation levels. Therefore, clients on warfarin therapy should be advised to avoid foods high in vitamin K to maintain the effectiveness of the medication. Choices B, C, and D are incorrect because increasing leafy green vegetables (choice B) would introduce more vitamin K, consuming a consistent amount of foods high in potassium (choice C) is not directly related to warfarin therapy, and limiting high-protein foods (choice D) is not a specific concern for clients on warfarin therapy.

3. Mr. Landon is scheduled to undergo a tracheostomy. Which nursing action is essential during tracheal suctioning?

• A. Using a water-soluble lubricant.
• B. Administering 100% oxygen before and after suctioning.
• C. Ensuring that the suction catheter is open during insertion.
• D. Assisting the client to assume a semi-Fowler's position during suctioning.

Correct answer: B

Rationale: Administering 100% oxygen before and after suctioning is crucial to prevent hypoxia, which can occur during tracheal suctioning. Hypoxia can lead to serious complications, making the provision of oxygen essential in maintaining adequate oxygenation levels for the patient undergoing tracheal suctioning. Choice A is incorrect because using a water-soluble lubricant is not directly related to the essential nursing action during tracheal suctioning. Choice C is incorrect as ensuring that the suction catheter is open during insertion is a basic requirement and not the essential action for oxygenation. Choice D is incorrect because assisting the client to assume a semi-Fowler's position is beneficial for comfort and airway alignment but is not as crucial as administering oxygen to prevent hypoxia.

4. Upon admission, a female client with breast cancer, liver, and spine metastases presents with constant, severe pain despite the continuous use of oxycodone (Percodan) and amitriptyline (Elavil) at home for pain management. What information is most crucial for the nurse to gather during the admission assessment?

• A. Sensory pattern, area, intensity, and nature of the pain.
• B. Identification of trigger points through palpation and manual pressure on painful areas.
• C. Current schedule and total dosages of medications used for breakthrough pain.
• D. Assessment of sympathetic responses indicative of acute pain onset.

Correct answer: A

Rationale: The most critical information for the nurse to obtain during the admission assessment of a client with severe pain due to breast cancer metastasis to the liver and spine is the sensory pattern, area, intensity, and nature of the pain. Understanding these details is essential to tailor appropriate pain management therapy effectively. By assessing the sensory pattern, area, intensity, and nature of pain, the nurse can better determine the underlying cause and choose the most suitable interventions to address the client's pain and improve their quality of life. Trigger points, medication dosages, and sympathetic responses are also important aspects of pain assessment but understanding the sensory aspects of pain is fundamental for providing optimal care in this scenario.

5. A client is admitted with a diagnosis of diabetic ketoacidosis (DKA). Which assessment finding should the nurse anticipate?

• A. Oliguria.
• B. Kussmaul respirations.
• C. Fruity odor on the breath.
• D. Blood glucose level of 250 mg/dL.

Correct answer: B

Rationale: Kussmaul respirations (B) are a deep and labored breathing pattern associated with diabetic ketoacidosis (DKA) and are expected in this condition. While oliguria (A), fruity odor on the breath (C), and elevated blood glucose level (D) are also signs of DKA, Kussmaul respirations are more specific and critical to the condition, indicating severe metabolic acidosis.

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