Nursing Elites

1. A nurse assesses a client who is recovering from a nephrostomy. Which assessment findings should alert the nurse to urgently contact the healthcare provider? (Select all that apply.)

• A. Foul-smelling drainage
• B. Bloody drainage at site
• C. A & B
• D. All of the above

Correct answer: C

Rationale: After a nephrostomy, the nurse should assess the client for complications and urgently notify the provider if there is foul-smelling drainage, bloody drainage at the site, or both. Foul-smelling drainage can indicate infection, while bloody drainage may suggest bleeding. Clear drainage is generally normal after a nephrostomy. A headache would not typically be directly related to nephrostomy complications. Therefore, options A and B are correct choices for urgent notification, making option C the correct answer.

2. In a client with congestive heart failure, the nurse would be correct in withholding a dose of digoxin without specific instruction from the healthcare provider if the client's

• A. serum digoxin level is 1.5 ng/mL.
• B. blood pressure is 104/68 mmHg.
• C. serum potassium level is 3 mEq/L.
• D. apical pulse is 68/min.

Correct answer: C

Rationale: The correct answer is C. Hypokalemia can precipitate digitalis toxicity in individuals on digoxin, increasing the risk of dangerous dysrhythmias. A serum potassium level of 3 mEq/L is below the normal range (3.5 to 5.5 mEq/L) and indicates hypokalemia, which can potentiate the effects of digoxin. Choices A, B, and D are not directly related to the potential for digitalis toxicity. Serum digoxin level of 1.5 ng/mL is within the therapeutic range, blood pressure of 104/68 mmHg is not a contraindication for administering digoxin, and an apical pulse of 68/min is within the normal range and not a reason to withhold digoxin.

3. A client with renal calculi is being assessed by a nurse. Which question should the nurse ask?

• A. Is there a family history of this problem?
• B. Do you consume cranberry juice?
• C. Do you urinate after sexual intercourse?
• D. Do you have burning sensation during urination?

Correct answer: A

Rationale: When assessing a client with renal calculi, it is important for the nurse to inquire about a family history of the problem. There is a genetic predisposition associated with renal stone formation, making it essential to assess if other family members have experienced renal stones. Choices B, C, and D are not directly related to renal calculi. Consuming cranberry juice is more relevant to urinary tract health, urinating after sexual intercourse is related to preventing urinary tract infections, and experiencing a burning sensation during urination is a symptom commonly associated with urinary tract infections, not renal calculi.

4. The healthcare provider assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis?

• A. Hyperaldosteronism causing increased sodium transport ion in renal tubules
• B. Decreased portacaval pressure with greater collateral circulation
• C. Decreased renin-angiotensin response related to increased renal blood flow
• D. Hypoalbuminemia that results in decreased colloidal oncotic pressure

Correct answer: D

Rationale: In clients with cirrhosis, hypoalbuminemia leads to decreased colloidal oncotic pressure. This reduction in oncotic pressure contributes to the development of edema in the feet and legs (pitting edema) and ascites in the abdomen. Hyperaldosteronism (choice A) would lead to sodium retention but is not the primary mechanism behind edema and ascites in cirrhosis. Decreased portacaval pressure with greater collateral circulation (choice B) is not directly related to the pathophysiology of edema and ascites in cirrhosis. Decreased renin-angiotensin response related to increased renal blood flow (choice C) does not play a significant role in the development of edema and ascites in cirrhosis compared to the impact of hypoalbuminemia on colloidal oncotic pressure.

5. A client with chronic renal failure is receiving erythropoietin therapy. The nurse should assess the client for which of the following side effects?

• A. Hypotension.
• B. Hypertension.
• C. Hyperglycemia.
• D. Hypercalcemia.

Correct answer: B

Rationale: The correct answer is B: Hypertension. Erythropoietin therapy can lead to an increase in blood pressure, making hypertension a common side effect that the nurse should closely monitor. Hypotension (choice A) is not typically associated with erythropoietin therapy. Hyperglycemia (choice C) and hypercalcemia (choice D) are not commonly linked to erythropoietin therapy in clients with chronic renal failure, making them incorrect choices.

Similar Questions