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. A client has a nursing diagnosis of 'Spiritual distress related to a loss of hope, secondary to impending death.' What intervention is best for the nurse to implement when caring for this client?

• A. Help the client accept the final stage of life.
• B. Assist and support the client in establishing short-term goals.
• C. Encourage the client to make future plans, even if they are unrealistic.
• D. Instruct the client's family to focus on positive aspects of the client's life.

Correct answer: B

Rationale: When a client is experiencing spiritual distress due to a loss of hope related to impending death, it is crucial for the nurse to assist and support the client in establishing short-term goals. This approach helps the client maintain hope and a sense of purpose, as achieving immediate goals can provide a sense of accomplishment and meaning. While acceptance of the final stage of life is important, helping the client set short-term goals is a more immediate and effective intervention in addressing spiritual distress. Encouraging the client to make future plans, especially if they are unrealistic, may not be beneficial as it could lead to further distress if those plans are unattainable. Instructing the client's family to focus on positive aspects of the client's life, though supportive, does not directly address the client's spiritual distress and loss of hope.

3. The healthcare professional is administering an intermittent infusion of an antibiotic to a client with an antecubital saline lock. After opening the roller clamp on the IV tubing, the alarm on the infusion pump indicates an obstruction. What action should be taken first?

• A. Check for a blood return.
• B. Reposition the client's arm.
• C. Remove the IV site dressing.
• D. Flush the lock with saline.

Correct answer: B

Rationale: Repositioning the client's arm is the initial action to take when encountering an obstruction with an antecubital saline lock. Repositioning may correct any bending at the elbow that could be causing the obstruction, allowing for smoother infusion flow. Checking for a blood return, removing the IV site dressing, or flushing the lock with saline would be subsequent actions once the obstruction is addressed. Checking for a blood return is done to confirm proper placement, removing the IV site dressing is necessary for site assessment, and flushing the lock with saline helps maintain patency but should not be the first action when an obstruction is detected.

4. When a student nurse is caught taking a copy of a client's medication administration record to help a friend prepare for the next day's clinical, what should the nurse respond first?

• A. Ask the nursing supervisor to meet with the student.
• B. Notify the student's clinical instructor of the situation.
• C. Ask the student if permission was obtained from the client.
• D. Explain that the records are hospital property and may not be removed.

Correct answer: D

Rationale: The correct response when a student nurse is caught taking a copy of a client's medication administration record is to explain that the records are hospital property and cannot be removed. It is essential to educate the student about the confidentiality and security of patient information, emphasizing that even with the client's consent, such actions are unacceptable. Option A is not the immediate action needed, as addressing the student directly should come first. Option B involves notifying another party before addressing the student directly. Option C is incorrect because even if the client gave permission, patient records are confidential and cannot be shared without authorization.

5. A community hospital is opening a mental health services department. Which document should the nurse use to develop the unit's nursing guidelines?

• A. Americans with Disabilities Act of 1990
• B. ANA Code of Ethics with Interpretative Statements
• C. ANA's Scope and Standards of Nursing Practice
• D. Patient's Bill of Rights of 1990

Correct answer: C

Rationale: The ANA's Scope and Standards of Nursing Practice are essential guidelines for nursing practice in various specialties, including mental health. The document outlines the expectations and responsibilities of nurses in providing high-quality care within their specific practice areas. In the context of opening a mental health services department, using the Scope and Standards specific to psychiatric–mental health nursing would ensure that the unit's nursing guidelines align with best practices and professional standards in mental health care. Choices A, B, and D are not focused on providing specific guidelines for nursing practice in a mental health services department, making them incorrect options.

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