Nursing Elites

1. The nurse is performing a peritoneal dialysis exchange on a client with chronic kidney disease (CKD). Which assessment finding should the nurse report to the healthcare provider?

• A. The appearance of the returning dialysate fluid is cloudy
• B. The client complains of slight shortness of breath during installation
• C. The amount of the returning dialysate fluid is greater than the amount instilled
• D. The client complains of abdominal fullness and cramping during instillation

Correct answer: A

Rationale: Cloudy dialysate fluid can indicate peritonitis, a serious complication of peritoneal dialysis. Peritonitis is an urgent condition that requires immediate evaluation and treatment. Reporting this finding promptly is crucial to prevent further complications. Choices B, C, and D are not indicative of peritonitis and do not require immediate reporting to the healthcare provider. Complaining of slight shortness of breath, having a greater return volume, and experiencing abdominal fullness and cramping are common occurrences during peritoneal dialysis and do not necessarily indicate an emergent issue.

2. What information should the nurse include in the discharge teaching plan of a client with low back pain who is taking cyclobenzaprine to control muscle spasms?

• A. Take this medication with or without food
• B. Avoid using heat or ice on injured muscles while taking this medication
• C. Use cold and allergy medications only as directed by a healthcare provider
• D. Discontinue all nonsteroidal anti-inflammatory medications

Correct answer: C

Rationale: The correct answer is C: 'Use cold and allergy medications only as directed by a healthcare provider.' It is essential to inform the client not to self-medicate with cold and allergy medications or make changes without consulting a healthcare provider to prevent potential drug interactions or adverse effects. Choice A is incorrect because cyclobenzaprine can be taken with or without food, so there is no specific requirement to take it on an empty stomach. Choice B is incorrect because using heat or ice on injured muscles while taking cyclobenzaprine is generally safe and can help with symptom management. Choice D is also incorrect because discontinuing nonsteroidal anti-inflammatory medications should be done under the guidance of a healthcare provider, but it is not a direct concern related to taking cyclobenzaprine for muscle spasms.

3. Which situation is a violation of client confidentiality, as described in the Health Insurance Portability and Accountability Act (HIPAA)?

• A. A sign-in sheet kept at the front desk listing clients' last names and the time of their arrival
• B. A nurse's handwritten notes from a telephone report discarded in the office wastebasket
• C. A computer monitor screen located at the nurse's station in a high-traffic area
• D. Privileged Health Information (PHI) given to an ambulance driver for the transfer of a client

Correct answer: C

Rationale: Choice C is a violation of client confidentiality as it exposes patient information to unauthorized individuals due to its location in a high-traffic area. HIPAA regulations require that electronic protected health information (ePHI) be safeguarded against unauthorized access, making the situation described in choice C a violation. Choices A, B, and D do not directly involve the exposure of patient information to unauthorized individuals. While choices A and B may pose some risks, they are not as severe as the direct exposure described in choice C. Choice D involves sharing information with an ambulance driver for a legitimate purpose, which does not violate HIPAA if done securely and in compliance with regulations.

4. Which type of wound would most likely require immediate intervention by the healthcare provider?

• A. Laceration
• B. Abrasion
• C. Contusion
• D. Ulceration

Correct answer: A

Rationale: A laceration would most likely require immediate intervention by the healthcare provider due to its deeper tissue damage, significant bleeding, and higher risk of infection compared to abrasions, contusions, and ulcerations. Lacerations often need prompt attention to control bleeding, clean the wound, and reduce the risk of infection. Abrasions are superficial wounds that usually do not require urgent attention as they tend to heal well on their own with basic wound care. Contusions are bruises that typically resolve on their own without immediate intervention. Ulcerations are open sores that may require intervention but not necessarily immediate action unless complicated by infection or other issues.

5. The client demonstrates an understanding of sliding scale insulin administration instructions by performing the procedure in which order?

• A. Obtain blood glucose level
• B. Verify the insulin prescription
• C. Draw insulin into insulin syringe
• D. Cleanse the selected site

Correct answer: A

Rationale: The correct order for the client to perform the procedure is to first obtain the blood glucose level. This step is crucial as it helps determine the appropriate dose of insulin based on the sliding scale. Verifying the insulin prescription, drawing insulin into the syringe, and cleansing the selected site are important steps in the process but should follow after obtaining the blood glucose level. Therefore, options B, C, and D are incorrect in terms of the initial steps required for sliding scale insulin administration.

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