Nursing Elites

1. A client with acute glomerulonephritis (GN) is being evaluated by a nurse. Which manifestation should the nurse recognize as a positive response to the prescribed treatment?

• A. The client has lost 11 pounds in the past 10 days.
• B. The client’s urine specific gravity is 1.048.
• C. No blood is observed in the client’s urine.
• D. The client’s blood pressure is 152/88 mm Hg.

Correct answer: A

Rationale: A weight loss of 11 pounds in the past 10 days indicates fluid loss, a positive response to treatment for acute glomerulonephritis. It signifies that the glomeruli are functioning adequately to filter excess fluid. A urine specific gravity of 1.048 is high, indicating concentrated urine, which is not a positive response in this context. Blood in the urine is not a typical finding in glomerulonephritis, so its absence is expected and does not indicate a positive response to treatment. A blood pressure of 152/88 mm Hg is elevated and may suggest kidney damage or fluid overload, which are not positive responses to treatment.

2. A nursing student is suctioning a client through a tracheostomy tube while a nurse observes. Which action by the student would prompt the nurse to intervene and demonstrate the correct procedure? Select all that apply.

• A. Setting the suction pressure to 60 mm Hg
• B. Applying suction throughout the procedure
• C. Assessing breath sounds before suctioning
• D. Placing the client in a supine position before the procedure

Correct answer: A

Rationale: The correct suction pressure for an adult client with a tracheostomy tube is typically between 80 to 120 mm Hg. Suction should be applied intermittently during catheter withdrawal to avoid damaging the airway. Assessing breath sounds before suctioning is important to ensure the procedure is necessary. Placing the client in a supine position before suctioning can compromise their airway; instead, the head of the bed should be elevated to facilitate proper drainage and reduce the risk of aspiration. Therefore, setting the suction pressure to 60 mm Hg is incorrect and would prompt the nurse to intervene and correct the procedure.

3. To evaluate the positive effect of furosemide (Lasix) 40 mg/day in a client with chronic kidney disease (CKD), what is the best action for the nurse to take?

• A. Obtain daily weights of the client.
• B. Auscultate heart and breath sounds.
• C. Palpate the client’s abdomen.
• D. Assess the client’s diet history.

Correct answer: A

Rationale: The correct answer is A. Furosemide (Lasix) is a loop diuretic used to manage fluid overload and hypertension in clients with CKD. Monitoring daily weights is crucial as weight changes reflect fluid status. Each kilogram of weight change approximately corresponds to 1 liter of fluid retention or loss, making it essential for evaluating the medication's effectiveness. Auscultating heart and breath sounds is more relevant for heart failure cases with fluid retention, not specifically for assessing the effect of furosemide in CKD. Palpating the abdomen is not a direct indicator of furosemide's effectiveness; instead, assessing for edema would be appropriate. While assessing the client's diet history is important to monitor electrolyte balance due to potassium loss with furosemide, it does not directly evaluate the medication's efficacy.

4. A client with type 1 diabetes mellitus who jogs daily is being taught by a nurse about the preferred sites for insulin absorption. What is the most appropriate site for this client?

• A. Arms
• B. Legs
• C. Abdomen
• D. Iliac crest

Correct answer: C

Rationale: The abdomen is the most appropriate site for insulin absorption in a client who jogs. When a client is involved in physical activity like jogging, the abdomen is preferred as it provides more consistent absorption compared to the arms or legs, which can have altered absorption rates due to increased blood flow during exercise. The iliac crest is not a common site for insulin injections and may not provide optimal absorption rates compared to the abdomen.

5. The nurse is preparing to administer digoxin to a patient who is newly admitted to the intensive care unit. The nurse reviews the patient’s admission electrolytes and notes a serum potassium level of 2.9 mEq/L. Which action by the nurse is correct?

• A. Administer the digoxin and monitor the patient’s electrocardiogram closely.
• B. Hold the digoxin dose and notify the provider of the patient’s lab values.
• C. Request an order for an intravenous bolus of potassium.
• D. Request an order for oral potassium supplements.

Correct answer: B

Rationale: In the scenario presented, the patient has a low serum potassium level, which can predispose the patient to digoxin toxicity. It is essential for the nurse to hold the digoxin dose and promptly notify the healthcare provider of the abnormal lab values. Option A is incorrect because administering digoxin without addressing the low potassium level can potentiate toxicity. Option C is inappropriate as potassium should not be given as an IV bolus, especially in the case of hypokalemia. Option D is incorrect because oral potassium supplements may not be sufficient for rapidly correcting severe hypokalemia in an acute care setting.

Similar Questions