Nursing Elites

1. After a myocardial infarction, why is the hospitalized client taught to move the legs while resting in bed?

• A. Prepare the client for ambulation.
• B. Promote urinary and intestinal elimination.
• C. Prevent thrombophlebitis and blood clot formation.
• D. Decrease the likelihood of pressure ulcer formation.

Correct answer: C

Rationale: The correct answer is C. Moving the legs helps prevent thrombophlebitis and blood clot formation by promoting venous return in clients on bed rest. This prevents stasis and clot formation in the lower extremities. Choices A, B, and D are incorrect because the primary goal of moving the legs is to prevent thrombophlebitis and blood clot formation, rather than preparing for ambulation, promoting elimination, or decreasing pressure ulcer formation. Ambulation preparation involves different exercises, urinary and intestinal elimination are not directly related to leg movements, and pressure ulcer prevention is more related to repositioning and skin care.

2. In a patient with cirrhosis, which of the following lab results is most concerning?

• A. Elevated liver enzymes.
• B. Low albumin levels.
• C. Elevated bilirubin levels.
• D. Low platelet count.

Correct answer: D

Rationale: In a patient with cirrhosis, a low platelet count is the most concerning lab result. Thrombocytopenia, or low platelet count, is common in cirrhosis due to impaired platelet production in the liver. It significantly increases the risk of bleeding and can lead to serious complications such as hemorrhage. Elevated liver enzymes (Choice A) are expected in cirrhosis but may not directly indicate the severity of the disease. Low albumin levels (Choice B) are common in cirrhosis and can contribute to fluid retention but do not pose an immediate risk of bleeding. Elevated bilirubin levels (Choice C) are also expected in cirrhosis and typically indicate impaired liver function but do not directly increase the risk of bleeding as much as a low platelet count.

3. 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.

4. The healthcare provider is assessing a client who is receiving hemodialysis for the first time. Which of the following findings should be reported to the healthcare provider immediately?

• A. Blood pressure of 150/90 mm Hg.
• B. Nausea and vomiting.
• C. Fatigue.
• D. Headache.

Correct answer: B

Rationale: Nausea and vomiting are critical symptoms that should be reported immediately when a client is receiving hemodialysis for the first time. These symptoms could indicate a severe complication, such as hypotension, infection, electrolyte imbalance, or other adverse reactions to the procedure. It is essential to address these symptoms promptly to prevent further complications or harm to the client. Choices A, C, and D are not immediate concerns during the first hemodialysis session and can be addressed appropriately after addressing the urgent issue of nausea and vomiting.

5. A client who has developed acute kidney injury (AKI) due to an aminoglycoside antibiotic has moved from the oliguric phase to the diuretic phase of AKI. Which parameters are most important for the nurse to plan to carefully monitor?

• A. Side effects of total parenteral nutrition (TPN) and Intralipids.
• B. Uremic irritation of mucous membranes and skin surfaces.
• C. Elevated creatinine and blood urea nitrogen (BUN).
• D. Hypovolemia and electrocardiographic (ECG) changes.

Correct answer: D

Rationale: During the diuretic phase of acute kidney injury (AKI), monitoring for hypovolemia and electrocardiographic (ECG) changes is crucial. Hypovolemia can occur due to the increased urine output in this phase, potentially leading to dehydration and electrolyte imbalances. Electrolyte imbalances can result in ECG changes, such as arrhythmias, which can be life-threatening. Therefore, careful monitoring of fluid status and ECG findings helps in preventing complications. Choices A, B, and C are not the most crucial parameters to monitor during the diuretic phase of AKI. Side effects of total parenteral nutrition (TPN) and Intralipids, uremic irritation of mucous membranes and skin surfaces, and elevated creatinine and blood urea nitrogen (BUN) are important considerations in other phases of AKI or in other conditions, but they are not the primary focus during the diuretic phase when hypovolemia and ECG changes take precedence.

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