Nursing Elites

1. A client with a family history of polycystic kidney disease (PKD is being assessed by a nurse. For which clinical manifestations should the nurse assess? (Select all that apply.)

• A. Nocturia
• B. Flank pain
• C. Increased abdominal girth
• D. B & C

Correct answer: D

Rationale: Clients with PKD commonly present with flank pain and increased abdominal girth due to abdominal distention caused by cysts. Bloody urine is also a common symptom due to tissue damage from PKD. Nocturia and dysuria are not typical manifestations of PKD. Constipation is not directly associated with PKD. Therefore, the correct choices are flank pain and increased abdominal girth, making option D the correct answer.

2. A client who just returned from the recovery room after a tonsillectomy and adenoidectomy is restless, and her pulse rate is increased. As the nurse continues the assessment, the client begins to vomit a copious amount of bright-red blood. The immediate nursing action is to:

• A. Notify the surgeon
• B. Continue the assessment
• C. Check the client’s blood pressure
• D. Obtain a flashlight, gauze, and a curved hemostat

Correct answer: A

Rationale: In the scenario described, the client's presentation with bright-red blood vomiting after a tonsillectomy and adenoidectomy is highly concerning for an immediate postoperative hemorrhage, which can be life-threatening. The priority action for the nurse is to notify the surgeon immediately. Prompt communication with the surgeon is vital to ensure swift intervention and appropriate management to address the hemorrhage effectively. Continuing the assessment, checking the client's blood pressure, or obtaining equipment are all secondary actions in this critical situation and would delay the necessary urgent intervention required to manage the hemorrhage effectively.

3. 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.

4. The client with chronic renal failure is being taught about the importance of fluid restrictions. Which of the following statements by the client indicates that the teaching has been effective?

• A. I can drink as much fluid as I want, as long as I take my medication.
• B. I will need to limit my fluid intake to prevent fluid overload.
• C. I can drink as much water as I want, as long as I limit other fluids.
• D. I will need to drink only when I am thirsty.

Correct answer: B

Rationale: The correct answer is B: 'I will need to limit my fluid intake to prevent fluid overload.' In chronic renal failure, fluid restrictions are crucial to prevent fluid overload and further damage to the kidneys. Option A is incorrect as unrestricted fluid intake can worsen the condition. Option C is also incorrect as total fluid intake needs to be restricted, not just other fluids. Option D is not ideal because thirst may not accurately reflect the body's fluid needs in chronic renal failure.

5. A patient is taking a thiazide diuretic and reports anorexia and fatigue. The nurse suspects which electrolyte imbalance in this patient?

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

Correct answer: D

Rationale: The correct answer is D: Hypokalemia. Thiazide diuretics lead to potassium loss, potentially causing hypokalemia. Anorexia and fatigue are common manifestations of hypokalemia. Hypercalcemia (choice A) and hypocalcemia (choice B) are not directly associated with thiazide diuretics. Hyperkalemia (choice C) is less likely than hypokalemia to be caused by thiazide diuretics.

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