Nursing Elites

1. A client with chronic renal failure is receiving sodium polystyrene sulfonate (Kayexalate). The nurse should monitor the client for which of the following?

• A. Hyponatremia.
• B. Hypokalemia.
• C. Hyperkalemia.
• D. Hypocalcemia.

Correct answer: C

Rationale: Correct Answer: The correct answer is C, 'Hyperkalemia.' Sodium polystyrene sulfonate (Kayexalate) is a medication used to treat high potassium levels (hyperkalemia) by exchanging sodium ions for potassium ions in the intestines, leading to potassium removal from the body. Therefore, the nurse should monitor the client for changes in potassium levels to assess the effectiveness of the medication and prevent potential complications related to hyperkalemia. Choice A, 'Hyponatremia,' is incorrect as Kayexalate does not primarily affect sodium levels. Choice B, 'Hypokalemia,' is incorrect as Kayexalate is used to treat high potassium levels, not low. Choice D, 'Hypocalcemia,' is incorrect as Kayexalate does not directly impact calcium levels.

2. A client in the emergency department is severely dehydrated and is prescribed 3 L of intravenous fluid over 6 hours. At what rate (mL/hr) should the nurse set the intravenous pump to infuse the fluids? (Record your answer using a whole number.)

• A. 500 mL/hr
• B. 400 mL/hr
• C. 550 mL/hr
• D. 600 mL/hr

Correct answer: A

Rationale: To calculate the rate of the intravenous pump, divide the total volume of fluid (3 L = 3000 mL) by the total time in hours (6 hours), which equals 500 mL/hr. The correct answer is A. Choice B (400 mL/hr) is incorrect as it would result in a slower infusion rate. Choice C (550 mL/hr) and Choice D (600 mL/hr) are incorrect as they would result in a faster infusion rate, exceeding the prescribed amount of fluid to be infused over 6 hours.

3. What is the most important nursing intervention for a patient with increased intracranial pressure (ICP)?

• A. Elevate the head of the bed to 30 degrees.
• B. Administer diuretics to reduce fluid volume.
• C. Administer corticosteroids to reduce inflammation.
• D. Keep the patient in a supine position.

Correct answer: A

Rationale: Elevating the head of the bed to 30 degrees is crucial for a patient with increased intracranial pressure (ICP) because it helps promote venous drainage from the brain, thereby reducing ICP. Keeping the head of the bed elevated helps facilitate cerebral perfusion and can prevent a further increase in ICP. Administering diuretics (Choice B) may be considered in some cases to reduce fluid volume, but it is not the most critical intervention for immediate ICP management. Administering corticosteroids (Choice C) is not typically indicated for managing increased ICP unless there is a specific underlying condition requiring their use. Keeping the patient in a supine position (Choice D) can actually worsen ICP by impeding venous outflow from the brain, making it an incorrect choice for this scenario.

4. A nurse is assessing a postoperative client on an hourly basis. The nurse notes that the client’s urine output for the past hour was 25 mL. Based on this finding, the nurse first:

• A. Calls the physician
• B. Increases the rate of the IV infusion
• C. Checks the client’s overall intake and output record
• D. Administers a 250-mL bolus of normal saline solution (0.9%)

Correct answer: C

Rationale: Clients are at risk of hypovolemia postoperatively, and decreased urine output can be an early sign. However, to accurately interpret this finding, the nurse must assess the overall fluid balance by checking the client’s intake and output records. Increasing the IV infusion rate or administering a bolus of normal saline solution without a physician's order would not be appropriate as these interventions require a prescription. The physician should be notified once the nurse has collected all necessary assessment data, including fluid status and vital signs.

5. A client arrived to the medical-surgical unit 4 hours after a transurethral resection of the prostate (TURP). A triple-lumen catheter for continuous bladder irrigation with normal saline is infusing, and the nurse observes dark, pink-tinged outflow with blood clots in the tubing and collection bag. Which action should the nurse take?

• A. Monitoring catheter drainage
• B. Decreasing the flow rate
• C. Irrigating the catheter manually
• D. Discontinuing infusing the solution

Correct answer: C

Rationale: In this scenario, the nurse should choose option C - irrigating the catheter manually. This action can help clear the clots from the catheter and ensure proper bladder drainage. Monitoring catheter drainage (option A) alone may not address the issue of clots obstructing the flow. Decreasing the flow rate (option B) could potentially worsen clot formation. Discontinuing the infusing solution (option D) without addressing the clots first may lead to inadequate irrigation and increase the risk of complications.

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