Nursing Elites

1. Four days following an abdominal aortic aneurysm repair, the client is exhibiting edema of both lower extremities, and pedal pulses are not palpable. Which action should the nurse implement first?

• A. Elevate extremities on pillows
• B. Evaluate edema for pitting
• C. Assess pulses with a vascular Doppler
• D. Wrap the feet with warmed blankets

Correct answer: C

Rationale: In this scenario, the priority action for the nurse is to assess pulses with a vascular Doppler. The absence of palpable pedal pulses following an abdominal aortic aneurysm repair raises concerns about compromised blood flow, which could lead to serious complications like ischemia or thrombosis. Evaluating and confirming the presence or absence of pulses is crucial to guide further interventions. Elevating extremities on pillows (Choice A) may be beneficial for managing edema, but it is not the immediate priority when pulses are not palpable. Evaluating edema for pitting (Choice B) can provide additional information about fluid status but does not address the primary concern of absent pulses. Wrapping the feet with warmed blankets (Choice D) is not appropriate in this situation and may not address the underlying vascular issue.

2. What discharge instruction is most important for a client after a kidney transplant?

• A. Weigh weekly.
• B. Report symptoms of secondary Candidiasis.
• C. Use daily reminders to take immunosuppressants.
• D. Stop cigarette smoking.

Correct answer: C

Rationale: After a kidney transplant, it is crucial for the client to adhere to the prescribed immunosuppressive therapy to prevent organ rejection. The client must take medications like corticosteroids and azathioprine (Imuran) regularly for the rest of their life. Using daily reminders is essential to ensure compliance with the medication regimen, as missing doses can increase the risk of organ rejection. Weighing weekly, reporting symptoms of secondary Candidiasis, and stopping cigarette smoking are important aspects of post-transplant care but may not be as critical as ensuring proper intake of immunosuppressants to prevent rejection.

3. The nurse is preparing to administer an antibiotic to a patient who has been receiving the antibiotic for 2 days after a culture was obtained. The nurse notes increased erythema and swelling, and the patient has a persistent high fever of 39°C. What is the nurse’s next action?

• A. Administer the antibiotic as ordered.
• B. Contact the provider to request another culture.
• C. Discuss the need to add a second antibiotic with the provider.
• D. Review the sensitivity results from the patient’s culture.

Correct answer: D

Rationale: In this scenario, the nurse is observing signs of a possible lack of response to the current antibiotic therapy, such as increased erythema, swelling, and persistent high fever. The next appropriate action for the nurse is to review the sensitivity results from the patient’s culture. This step is crucial to determine if the current antibiotic is effective against the causative organism. If the sensitivity results indicate resistance to the current antibiotic, the antibiotic should be discontinued, and the provider should be notified for a change in therapy. Contacting the provider to request another culture is not the immediate priority, as the existing culture results need to be reviewed first. Adding a second antibiotic should only be considered after confirming the sensitivity results, as unnecessary antibiotic use can lead to antimicrobial resistance.

4. A client recovering from a cystoscopy is being assessed by a nurse. Which assessment findings should alert the nurse to urgently contact the health care provider? (Select all that apply.)

• A. Decrease in urine output
• B. Blood clots present in the urine
• C. Prescription for metformin
• D. A & B

Correct answer: D

Rationale: After a cystoscopy, the nurse should monitor urine output and promptly contact the provider if there is a decrease or absence of urine output. Additionally, the nurse should assess for blood in the urine. While some pink-tinged urine may be expected, the presence of gross bleeding or blood clots warrants immediate provider notification. Tolerating oral fluids is a positive sign and does not require urgent intervention. Metformin would be a concern if the client received contrast dye, which is not used in a cystoscopy. A burning sensation when urinating is a common post-procedure experience and does not necessitate contacting the provider. Therefore, choices A and B are the correct answers as they indicate potentially serious complications that require immediate attention, while choices C and D do not align with urgent concerns following a cystoscopy.

5. A nurse has a prescription to discontinue a client’s nasogastric tube. The nurse auscultates the client’s bowel sounds, positions the client properly, and flushes the tube with 15 mL of air to clear secretions. The nurse then instructs the client to take a deep breath and:

• A. Exhale during tube removal
• B. Bear down during tube removal
• C. Hold the breath during tube removal
• D. Breathe normally during tube removal

Correct answer: C

Rationale: The correct answer is to instruct the client to hold their breath during tube removal. This is because the airway may be temporarily obstructed during the removal process. By holding their breath, the client can help prevent aspiration or discomfort during the removal of the nasogastric tube. Choices A, B, and D are incorrect because exhaling, bearing down, or breathing normally during tube removal may not provide the necessary protection against aspiration or discomfort that holding the breath does.

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