Nursing Elites

1. A nurse assesses a client who is recovering from a radical nephrectomy for renal cell carcinoma. The nurse notes that the client’s blood pressure has decreased from 134/90 to 100/56 mm Hg and urine output is 20 mL for this past hour. Which action should the nurse take?

• A. Position the client to lay on the surgical incision.
• B. Measure the specific gravity of the client’s urine.
• C. Administer intravenous pain medications.
• D. Assess the rate and quality of the client’s pulse.

Correct answer: D

Rationale: The nurse should first fully assess the client for signs of volume depletion and shock, and then notify the provider. The radical nature of the surgery and the proximity of the surgery to the adrenal gland put the client at risk for hemorrhage and adrenal insufficiency. Hypotension is a clinical manifestation associated with both hemorrhage and adrenal insufficiency. Hypotension is particularly dangerous for the remaining kidney, which must receive adequate perfusion to function effectively. Re-positioning the client, measuring specific gravity, and administering pain medication would not provide data necessary to make an appropriate clinical decision, nor are they appropriate interventions at this time.

2. When preparing a client for intravenous pyelography (IVP), which action by the nurse is most important?

• A. Administering a sedative
• B. Encouraging fluid intake
• C. Administering an oral preparation of radiopaque dye
• D. Questioning the client about allergies to iodine or shellfish

Correct answer: D

Rationale: The most crucial action for the nurse when preparing a client for intravenous pyelography (IVP) is to question the client about allergies to iodine or shellfish. Some IVP dyes contain iodine, and if the client is allergic to iodine or shellfish, they may experience severe allergic reactions such as itching, hives, rash, throat tightness, difficulty breathing, or bronchospasm. Administering a sedative (Choice A) may be needed for relaxation during the procedure, encouraging fluid intake (Choice B) is generally beneficial but not the most crucial for IVP preparation, and administering radiopaque dye (Choice C) should only be done after confirming the client's safety regarding allergies to iodine or shellfish.

3. The nurse assesses a client who is newly diagnosed with hyperthyroidism and observes that the client's eyeballs are protuberant, causing a wide-eyed appearance and eye discomfort. Based on this finding, which action should the nurse include in the client's plan of care?

• A. Assess for signs of increased intracranial pressure
• B. Prepare to administer intravenous levothyroxine
• C. Review the client's serum electrolyte values
• D. Obtain a prescription for artificial tear drops

Correct answer: D

Rationale: In hyperthyroidism, eye discomfort due to protuberant eyeballs (exophthalmos) can be alleviated by using artificial tear drops. These drops help prevent complications associated with dry eyes and promote comfort. Assessing for signs of increased intracranial pressure (Choice A) is not directly related to the client's eye discomfort from hyperthyroidism. Administering intravenous levothyroxine (Choice B) is not the appropriate intervention for managing eye discomfort in hyperthyroidism. Reviewing serum electrolyte values (Choice C) is important in hyperthyroidism but is not directly addressing the client's current eye discomfort and protuberant eyeballs.

4. 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.

5. The nurse assumes care for a patient who is currently receiving a dose of intravenous vancomycin (Vancocin) infusing at 20 mg/min. The nurse notes red blotches on the patient’s face, neck, and chest and assesses a blood pressure of 80/55 mm Hg. Which action will the nurse take?

• A. Request an order for IV epinephrine to treat anaphylactic shock.
• B. Slow the infusion to 10 mg/min and observe the patient closely.
• C. Stop the infusion and obtain an order for a BUN and serum creatinine.
• D. Suspect Stevens-Johnson syndrome and notify the provider immediately.

Correct answer: B

Rationale: When vancomycin is infused too rapidly, “red man” syndrome may occur; the rate should be 10 mg/min to prevent this. This is a toxic reaction, not an allergic one, so epinephrine is not indicated. Stevens-Johnson syndrome is characterized by a rash and fever. Red man syndrome is not related to renal function.

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