Nursing Elites

1. While caring for a client receiving hemodialysis, which action should the nurse include in the plan of care?

• A. Withhold all medications until after dialysis.
• B. Check the vascular access site for bleeding after dialysis.
• C. Rehydrate with dextrose 5% in water for hypotension.
• D. Give an antibiotic 30 minutes before dialysis.

Correct answer: B

Rationale: The correct action the nurse should include in the plan of care when caring for a client receiving hemodialysis is to check the vascular access site for bleeding after dialysis. This is crucial to monitor for any signs of bleeding or complications at the access site. Withholding all medications until after dialysis (Choice A) is not necessary unless specified for certain medications. Rehydrating with dextrose 5% in water for hypotension (Choice C) is not appropriate for addressing hypotension related to hemodialysis. Giving an antibiotic 30 minutes before dialysis (Choice D) is not typically indicated unless there is a specific medical indication for prophylactic antibiotic use.

2. A nurse is caring for a client who is receiving continuous enteral feedings through a nasogastric tube. Which of the following actions should the nurse take?

• A. Keep the head of the bed elevated to 15 degrees.
• B. Change the feeding bag every 48 hours.
• C. Administer the feeding through a large-bore syringe.
• D. Flush the tube with 0.9% sodium chloride every 4 hours.

Correct answer: D

Rationale: The correct action the nurse should take is to flush the tube with 0.9% sodium chloride every 4 hours. This helps maintain patency and prevents clogs during enteral feedings. Keeping the head of the bed elevated to 15 degrees (Choice A) is important for preventing aspiration but is not directly related to tube care. Changing the feeding bag every 48 hours (Choice B) is not a standard practice as the bag should be changed every 24 hours to prevent bacterial growth. Administering the feeding through a large-bore syringe (Choice C) is incorrect as enteral feedings should be given through an appropriate feeding pump for accuracy and safety.

3. A nurse is teaching a client who has heart failure about a new prescription for furosemide. Which of the following statements should the nurse include?

• A. You should take this medication in the morning to reduce urination during the day.
• B. You may experience ringing in your ears as a side effect.
• C. This medication may cause your potassium level to decrease.
• D. You should consume foods high in potassium while taking this medication.

Correct answer: C

Rationale: The correct statement to include when teaching a client about furosemide is that it may cause potassium levels to decrease. Furosemide is a loop diuretic that can lead to hypokalemia, emphasizing the importance of monitoring potassium levels. Option A is incorrect because furosemide is usually taken in the morning to prevent nighttime diuresis. Option B is incorrect as tinnitus, not ringing in the ears, is associated with furosemide use. Option D is wrong because while it is essential to monitor potassium levels, the client should be advised to consume foods high in potassium to prevent hypokalemia.

4. A nurse is assessing a client who has myasthenia gravis. Which of the following findings should the nurse expect?

• A. Bradycardia.
• B. Increased muscle strength.
• C. Diarrhea.
• D. Decreased deep tendon reflexes.

Correct answer: D

Rationale: The correct answer is D: Decreased deep tendon reflexes. In myasthenia gravis, muscle weakness is a common manifestation, leading to decreased deep tendon reflexes. Bradycardia (choice A) is not typically associated with myasthenia gravis. Increased muscle strength (choice B) is unlikely as muscle weakness is a hallmark of this condition. Diarrhea (choice C) is not a typical finding in myasthenia gravis.

5. A nurse is caring for a client who is 2 hours postoperative following a thoracotomy. Which of the following findings should the nurse report to the provider?

• A. Chest tube drainage of 60 mL/hr
• B. Oxygen saturation of 95%
• C. Chest tube drainage of 120 mL/hr
• D. Heart rate of 88/min

Correct answer: C

Rationale: The correct answer is C. Chest tube drainage of more than 100 mL/hr may indicate active bleeding, which is a serious complication post-thoracotomy surgery. This finding should be reported to the healthcare provider immediately for further evaluation and intervention. Choices A, B, and D are within normal limits for a client 2 hours post-thoracotomy and do not require immediate reporting. Oxygen saturation of 95% is acceptable, and a heart rate of 88/min is within the normal range for an adult.

Similar Questions