Nursing Elites

1. A client is recovering after a nephrostomy tube was placed 6 hours ago. The nurse notes drainage in the tube has decreased from 40 mL/hr to 12 mL over the last hour. Which action should the nurse take?

• A. Document the finding in the client’s record.
• B. Evaluate the tube as working in the hand-off report.
• C. Clamp the tube in preparation for removing it.
• D. Assess the client’s abdomen and vital signs.

Correct answer: D

Rationale: The correct action for the nurse to take in this situation is to assess the client’s abdomen and vital signs. The nephrostomy tube should have a consistent amount of drainage, and a decrease may indicate obstruction. Before notifying the provider, the nurse must assess the client for pain, distention, and changes in vital signs. This assessment is crucial to gather essential information to report accurately. Documenting the finding without further assessment may delay necessary intervention. Evaluating the tube as working in the hand-off report or clamping the tube prematurely are not appropriate actions and could lead to complications if there is an obstruction.

2. After educating a client with hypertension secondary to renal disease, the nurse assesses the client’s understanding. Which statement made by the client indicates a need for additional teaching?

• A. I can prevent more damage to my kidneys by managing my blood pressure.
• B. If I have increased urination at night, I need to drink less fluid during the day.
• C. I need to see the registered dietitian to discuss limiting my protein intake.
• D. It is important that I take my antihypertensive medications as directed.

Correct answer: B

Rationale: Choice B is incorrect because the client should not restrict fluids during the day due to increased urination at night. Clients with renal disease may be prescribed fluid restrictions, and they should be thoroughly assessed for potential dehydration. To decrease increased nocturnal voiding, clients should consume fluids earlier in the day. Choices A, C, and D are correct statements. Managing blood pressure is crucial to slow the progression of renal dysfunction. Limiting protein intake is important in renal disease management, and clients should be referred to a dietitian as needed. Taking antihypertensive medications as directed is essential for blood pressure control.

3. A pregnant client tells the nurse, “I am experiencing a burning pain when I urinate.” How should the nurse respond?

• A. This means labor will start soon. Prepare to go to the hospital.
• B. You probably have a urinary tract infection. Drink more cranberry juice.
• C. Make an appointment with your provider to have your infection treated.
• D. Your pelvic wall is weakening. Pelvic muscle exercises should help.

Correct answer: C

Rationale: Pregnant clients with a urinary tract infection require prompt and aggressive treatment because cystitis can lead to acute pyelonephritis during pregnancy. The nurse should encourage the client to make an appointment and have the infection treated. Burning pain when urinating does not indicate the start of labor or weakening of pelvic muscles. Choice A is incorrect because burning pain during urination does not signify the start of labor. Choice B is incorrect because while cranberry juice may help prevent urinary tract infections, it is not a treatment. Choice D is incorrect because burning pain when urinating is not indicative of weakening pelvic muscles.

4. After pericardiocentesis for cardiac tamponade, for which signs should the nurse assess the client to determine if tamponade is recurring?

• A. Decreasing pulse
• B. Rising blood pressure
• C. Distant muffled heart sounds
• D. Falling central venous pressure (CVP)

Correct answer: C

Rationale: After pericardiocentesis for cardiac tamponade, the nurse should assess for distant muffled heart sounds that were noted before the procedure. If these sounds return, it could indicate recurring pericardial effusion and potential tamponade. Therefore, the correct answer is the return of distant muffled heart sounds (Option C). Decreasing pulse (Option A) and falling central venous pressure (Option D) are not specific signs of recurring tamponade. Rising blood pressure (Option B) is also not a typical sign of tamponade recurrence; in fact, hypotension is more commonly associated with tamponade.

5. The client has been receiving peritoneal dialysis. The nurse should assess the client for which of the following complications that is most likely to occur?

• A. Electrolyte imbalance
• B. Peritonitis
• C. Infection
• D. Hyperglycemia

Correct answer: B

Rationale: Peritonitis is the most likely complication to occur in clients receiving peritoneal dialysis due to the risk of infection. Peritonitis is a serious inflammation of the peritoneum lining the abdominal cavity, commonly caused by infection. While electrolyte imbalance and hyperglycemia are possible complications in some cases, peritonitis poses a more immediate and severe threat to the client's health. Infection is a general term that can encompass peritonitis but is not as specific as directly identifying peritonitis as the primary concern in this scenario.

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