Nursing Elites

1. A client with polycystic kidney disease (PKD) is being discharged. Which statements should the nurse include in this client’s discharge teaching? (Select all that apply.)

• A. Take your blood pressure every morning.
• B. Weigh yourself at the same time each day.
• C. Contact your provider if you have visual disturbances.
• D. All of the above

Correct answer: D

Rationale: A client with polycystic kidney disease (PKD) should be educated on monitoring their blood pressure daily and weighing themselves consistently to detect any changes promptly. It is essential to contact the healthcare provider if visual disturbances occur, as this could indicate a complication such as a berry aneurysm associated with PKD. Foul-smelling or bloody urine should also prompt notification to the provider as they could signify urinary tract infections or glomerular injury. Choices A, B, and C are correct as they address crucial aspects of managing PKD and its potential complications. Choices A and B help in monitoring for changes in blood pressure and fluid status, while choice C focuses on detecting possible neurological complications. Choices A, B, and C are relevant to PKD management and should be included in the client's discharge teaching. Choices that mention diarrhea and renal stones are not directly associated with PKD; therefore, teaching related to these conditions would be irrelevant in this context.

2. The client is receiving teletherapy radiation for a malignant tumor. Which instruction regarding skin care of the portal site should the nurse provide?

• A. Protect the skin of the radiation portal site from sunlight exposure
• B. Apply moisturizing lotions daily to the radiation portal site
• C. Avoid washing the skin inside the radiation portal site
• D. Remove the ink marks of the portal after each radiation treatment

Correct answer: A

Rationale: Protecting the skin from sunlight exposure is crucial to prevent radiation burns and additional skin damage at the treatment site. Sun exposure can exacerbate skin reactions caused by radiation therapy. Applying moisturizing lotions daily may introduce foreign substances or irritants to the treated area, leading to potential complications. Washing the skin inside the radiation portal site is important for maintaining cleanliness and preventing infections. Removing the ink marks after each treatment is unnecessary and may cause unnecessary skin irritation and trauma.

3. The client with chronic renal failure is being educated about the importance of a low-sodium diet. Which of the following statements by the client indicates a need for further teaching?

• A. I can eat canned vegetables as long as I rinse them first.
• B. I can use table salt sparingly.
• C. I can eat frozen dinners if they are labeled low-sodium.
• D. I can eat whatever I want as long as I avoid salty foods.

Correct answer: B

Rationale: The correct answer is B. Clients with chronic renal failure need to strictly limit their sodium intake. Advising the client to use table salt sparingly is incorrect as they should avoid table salt altogether to adhere to a low-sodium diet. Choice A is correct as rinsing canned vegetables can help reduce their sodium content. Choice C is correct as consuming frozen dinners labeled low-sodium can be a suitable option. Choice D is incorrect as it implies that avoiding only salty foods is sufficient, when in fact, overall sodium intake needs to be monitored closely.

4. The client with deep vein thrombosis (DVT) in the left lower leg is receiving heparin therapy. Which of the following assessments is the most important for the nurse to perform?

• A. Measure the circumference of the left leg.
• B. Assess for signs of bleeding, such as bruising or hematuria.
• C. Monitor the client's vital signs.
• D. Monitor the client's respiratory status.

Correct answer: B

Rationale: The most important assessment for a client with DVT on heparin therapy is to monitor for signs of bleeding, such as bruising or hematuria. Heparin is an anticoagulant medication that can increase the risk of bleeding. Assessing for bleeding is crucial to prevent complications like hemorrhage. Measuring the circumference of the leg may be relevant for assessing for edema but is not as critical as monitoring for bleeding. Monitoring vital signs and respiratory status are important aspects of care but are not the priority when the client is on heparin therapy for DVT.

5. The nurse is collecting information from a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?

• A. Presence and activity of bowel sounds
• B. Color and consistency of feces
• C. Eating patterns and dietary intake
• D. Level and amount of physical activity

Correct answer: C

Rationale: In chronic pancreatitis, managing abdominal pain is crucial, and assessing the client's eating patterns and dietary intake is essential. Dietary modifications can help alleviate symptoms and reduce the workload on the pancreas. Choices A, B, and D are not directly related to pain management in chronic pancreatitis. Bowel sounds, fecal characteristics, and physical activity may provide important information in other conditions but are not the priority in this scenario.

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