Nursing Elites

1. A client with chronic kidney disease missed dialysis yesterday to attend a funeral. The client's wife calls the home health nurse and reports that her husband is lethargic and hard to arouse. Which instruction is most important for the nurse to provide?

• A. Apply the client's home oxygen.
• B. Check for a thrill and bruit at the client's dialysis access site.
• C. Ensure the client avoids salt intake for the rest of the day.
• D. Take the client to the emergency department (ED).

Correct answer: D

Rationale: In this scenario, the most crucial instruction for the nurse to provide is to take the client to the emergency department (ED). Missing dialysis can lead to severe complications in clients with chronic kidney disease, such as electrolyte imbalances and fluid overload. Lethargy and difficulty in arousing the client suggest a critical situation that requires immediate medical attention. Applying home oxygen, checking the dialysis access site, and ensuring salt intake avoidance, although important, are not as urgent as seeking emergency care to address the potential severe complications from missed dialysis.

2. A client is scheduled to undergo computerized tomography (CT) with contrast for evaluation of an abdominal mass. The nurse should tell the client that:

• A. The test may be painful
• B. The test takes 2 to 3 hours
• C. Food and fluids are not allowed for 4 hours after the test
• D. Dye is injected and may cause a warm flushing sensation

Correct answer: D

Rationale: The correct answer is D. A contrast-aided CT scan involves the injection of dye to enhance the images obtained. The dye may cause a warm flushing sensation when injected, which is a common side effect. Choices A, B, and C are incorrect. CT with contrast is generally not a painful procedure, the duration of the test does not usually take 2 to 3 hours, and restrictions on food and fluids are typically before the test, not afterward.

3. A client with a history of peptic ulcer disease (PUD) is admitted after vomiting bright red blood several times over the course of 2 hours. In reviewing the laboratory results, the nurse finds the client's hemoglobin is 12 g/dL (120g/L) and the hematocrit is 35% (0.35). Which action should the nurse prepare to take?

• A. Continue monitoring for blood loss
• B. Administer 1,000 mL (1L) of normal saline
• C. Transfuse 2 units of platelets
• D. Prepare the client for emergency surgery

Correct answer: D

Rationale: The correct answer is to prepare the client for emergency surgery. The client's presentation with bright red blood in vomitus suggests active bleeding, which is a medical emergency. With a hemoglobin of 12 g/dL and a hematocrit of 35%, the client is likely experiencing significant blood loss that may require surgical intervention to address the source of bleeding. Continuing to monitor for blood loss (Choice A) is not appropriate in this acute situation where immediate action is necessary. Administering normal saline (Choice B) may help with fluid resuscitation but does not address the underlying cause of bleeding. Transfusing platelets (Choice C) is not indicated in this scenario as platelets are involved in clot formation and are not the primary treatment for active bleeding in this context.

4. A nurse teaches clients about the difference between urge incontinence and stress incontinence. Which statements should the nurse include in this education? (Select all that apply.)

• A. Urge incontinence involves a post-void residual volume less than 50 mL.
• B. Stress incontinence occurs due to weak pelvic floor muscles.
• C. Stress incontinence usually occurs in people with dementia.
• D. Urge incontinence can be managed by increasing fluid intake.

Correct answer: B

Rationale: The correct statement to include in the education about urge incontinence and stress incontinence is choice B. Stress incontinence occurs due to weak pelvic floor muscles or urethral sphincter, leading to the inability to tighten the urethra sufficiently to overcome increased detrusor pressure. This condition is common after childbirth when pelvic muscles are stretched and weakened. Urge incontinence, on the other hand, is characterized by the inability to suppress the contraction signal from the detrusor muscle. It is often associated with abnormal detrusor contractions, which can be due to neurological abnormalities rather than post-void residual volume. Choice A is incorrect because urge incontinence is not defined by post-void residual volume. Choice C is incorrect as stress incontinence is not usually linked to dementia. Choice D is incorrect because increasing fluid intake is not a management strategy for urge incontinence.

5. During a routine clinic visit, a nurse is assessing a 48-year-old client with a history of smoking. The client, who exercises regularly, reports calf pain during exercise that disappears at rest. Which of the following findings requires further evaluation?

• A. Heart rate of 57 bpm.
• B. SpO2 of 94% on room air.
• C. Blood pressure of 134/82.
• D. Ankle-brachial index of 0.65.

Correct answer: D

Rationale: An Ankle-Brachial Index of 0.65 suggests moderate arterial vascular disease in a client experiencing intermittent claudication, indicating compromised blood flow to the lower extremities during exercise. This finding requires further evaluation to assess the severity of arterial insufficiency and determine appropriate interventions. Choice A (Heart rate of 57 bpm) is within the normal range for an adult at rest and indicates good cardiovascular fitness. Choice B (SpO2 of 94% on room air) is slightly lower than the normal range but is generally acceptable in a healthy individual. Choice C (Blood pressure of 134/82) falls within the normal range and does not raise immediate concerns in this context.

Similar Questions