Nursing Elites

1. A client with suspected renal disease is to undergo a renal biopsy. The nurse plans to include which statement in the teaching session?

• A. "You will be positioned lying down during the examination procedure."?
• B. "Portions of the procedure will cause pain or discomfort."?
• C. "You may be given anesthesia during the procedure."?
• D. "You should refrain from eating or drinking before the procedure."?

Correct answer: B

Rationale: The correct answer is to inform the client that portions of the renal biopsy procedure can cause pain or discomfort, particularly when the sample is being withdrawn. This prepares the client for any unpleasant sensations during the procedure. Answer A is incorrect because the client will be positioned lying down, not sitting up, during the exam, so this information is not relevant to include in the teaching session. Answer C is incorrect as anesthesia is commonly used to numb the area for a renal biopsy, reducing pain, so the client can expect to receive anesthesia. Answer D is incorrect because clients are usually instructed to refrain from eating or drinking for a period before the procedure to prevent any complications during the biopsy, not simply before the study.

2. Why might the physician order antibiotics to be given through the central venous access device (CVAD) rather than through a peripheral IV line if the CVAD becomes infected?

• A. To prevent infiltration of the peripheral line
• B. To reduce the pain and discomfort associated with antibiotic administration in a small vein
• C. To lessen the chance of an allergic reaction to the antibiotic
• D. To attempt to eliminate microorganisms in the catheter and prevent having to remove it

Correct answer: D

Rationale: When a patient's central venous access device (CVAD) becomes infected, administering antibiotics through the line is essential to attempt to eliminate microorganisms within the catheter. The goal is to prevent the necessity of removing the catheter, which might be required if the infection persists. Choice A, 'To prevent infiltration of the peripheral line,' is incorrect as the priority is addressing the catheter infection, not preventing issues with a peripheral line. Choice B, 'To reduce the pain and discomfort associated with antibiotic administration in a small vein,' is not relevant to the rationale for choosing the CVAD for antibiotic administration. Choice C, 'To lessen the chance of an allergic reaction to the antibiotic,' is also incorrect as the main focus is managing the catheter-associated infection rather than allergy prevention.

3. The nurse suspects an elderly client has been the victim of abuse. The client denies abuse and declines assistance. The nurse's next action should be to:

• A. respect the client's decision to refuse assistance.
• B. report the incident to the authorities.
• C. arrange an appointment with the client's family.
• D. educate the client about available services.

Correct answer: D

Rationale: In cases where elderly clients deny abuse and refuse assistance, it is crucial for the nurse to respect their autonomy while also ensuring their safety. Educating the client about available services is the appropriate action as it empowers the client with information without imposing any decisions on them. It allows the client to make informed choices regarding their well-being. Reporting the incident to the authorities (Choice B) may be necessary if there is immediate danger, but in this scenario, the client denies abuse. Arranging an appointment with the client's family (Choice C) may not be appropriate without the client's consent or in cases where the family might be involved in the abuse. Simply doing nothing (Choice A) is not the best course of action as the nurse should still provide support and resources to the client.

4. A 25-year-old male is brought to the emergency room with a piece of metal in his eye. Which action by the nurse is correct?

• A. Use a magnet to remove the object.
• B. Rinse the eye thoroughly with saline.
• C. Cover both eyes with paper cups.
• D. Administer eye drops immediately.

Correct answer: C

Rationale: Covering both eyes with paper cups is the correct action as it helps prevent consensual movement of the affected eye. Attempting to remove the object with a magnet might cause trauma, making choice A incorrect. While rinsing the eye with saline may be necessary, it should be ordered by a doctor and is not the initial action for the nurse, making choice B incorrect. Administering eye drops immediately, as in choice D, is not appropriate in this scenario and does not address the primary concern of preventing further damage by limiting eye movement.

5. The nurse observes bilateral bruises on the arms of an elderly client in a long-term care facility. Which of the following questions should the nurse ask this client?

• A. "How did you get those bruises?"?
• B. "Did someone grab you by your arms?"?
• C. "Do you fall often?"?
• D. "What did you bump against?"?

Correct answer: B

Rationale: The correct answer is asking, "Did someone grab you by your arms?"? This question is direct and addresses the possibility of abuse, which is crucial when dealing with suspected abuse cases. It is important to ask direct questions in a sensitive and non-accusatory manner to gather information. Choice A is too general and may not prompt a disclosure of abuse. Choice C assumes falling as the cause without addressing abuse directly. Choice D is vague and does not specifically inquire about potential abuse, making it less effective in identifying abuse cases compared to the correct choice.

Similar Questions