Nursing Elites

1. The nurse is assessing a client with a diagnosis of pre-renal acute kidney injury (AKI). Which condition would the nurse expect to find in the client’s recent history?

• A. Pyelonephritis
• B. Myocardial infarction
• C. Bladder cancer
• D. Kidney stones

Correct answer: B

Rationale: In pre-renal acute kidney injury, there is a decrease in perfusion to the kidneys. Myocardial infarction can lead to decreased blood flow to the kidneys, causing pre-renal AKI. Pyelonephritis is an intrinsic/intrarenal cause of AKI involving kidney damage. Bladder cancer and kidney stones are post-renal causes of AKI due to urinary flow obstruction, not related to perfusion issues seen in pre-renal AKI.

2. Which of the following is the most important nursing action when administering a blood transfusion?

• A. Monitoring the patient's blood pressure.
• B. Monitoring the patient's temperature.
• C. Monitoring the patient's heart rate.
• D. Monitoring the patient's oxygen saturation.

Correct answer: A

Rationale: The most important nursing action when administering a blood transfusion is monitoring the patient's blood pressure. This is crucial because monitoring blood pressure allows for the prompt identification of any signs of adverse transfusion reactions, such as transfusion reactions or fluid overload. Immediate intervention can be initiated if any complications arise. While monitoring temperature, heart rate, and oxygen saturation are also essential aspects of patient care, they are not as critical as blood pressure monitoring during a blood transfusion. Therefore, the correct answer is to monitor the patient's blood pressure.

3. A client admitted to the hospital with a diagnosis of acute pancreatitis has blood drawn for several serum laboratory tests. Which of the following serum amylase values, noted by the nurse reviewing the results, would be expected in this client at this time?

• A. 48 units/L
• B. 97 units/L
• C. 150 units/L
• D. 395 units/L

Correct answer: D

Rationale: The correct answer is D: "395 units/L." The normal serum amylase range is 25 to 151 units/L. In acute pancreatitis, the amylase level is greatly increased, typically exceeding the upper limit of the normal range. Choices A, B, and C fall within the normal range of serum amylase levels and would not be expected in a client with acute pancreatitis.

4. What is an expected outcome when a client is receiving an IV administration of furosemide?

• A. Increased blood pressure.
• B. Increased urine output.
• C. Decreased pain.
• D. Decreased premature ventricular contractions.

Correct answer: B

Rationale: The correct answer is B: Increased urine output. Furosemide is a loop diuretic that works by inhibiting the reabsorption of sodium and chloride in the ascending loop of Henle in the kidneys, leading to increased urine production. This diuretic effect helps to reduce fluid volume in the body, making it an expected outcome when a client is receiving furosemide. Choice A, increased blood pressure, is incorrect because furosemide typically causes a decrease in blood pressure due to its diuretic effect. Choice C, decreased pain, and choice D, decreased premature ventricular contractions, are unrelated to the pharmacological action of furosemide.

5. The healthcare provider is assessing a client undergoing peritoneal dialysis. Which of the following findings should be reported immediately to the physician?

• A. Clear dialysate outflow.
• B. Clear dialysate inflow.
• C. Cloudy dialysate outflow.
• D. Increased blood pressure.

Correct answer: C

Rationale: Cloudy dialysate outflow should be reported immediately to the physician as it is a concerning sign of peritonitis, a severe infection of the peritoneum. Peritonitis is a serious complication of peritoneal dialysis that requires prompt medical intervention to prevent further complications. Clear dialysate outflow and inflow are normal findings in peritoneal dialysis and do not indicate an immediate need for intervention. Increased blood pressure, while important to monitor, is not directly related to peritoneal dialysis and would not be the priority over the potentially life-threatening complication of peritonitis.

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