Nursing Elites

1. The client with chronic renal failure is receiving education on managing fluid intake. Which of the following statements by the client indicates a need for further teaching?

• A. I can drink as much water as I want.
• B. I should increase my intake of high-sodium foods.
• C. I can skip a dialysis session if I feel tired.
• D. I can eat whatever I want as long as I take my medications.

Correct answer: C

Rationale: Choice C is the correct answer. Clients with chronic renal failure should not skip dialysis sessions, as this can lead to serious complications. Dialysis is crucial for managing fluid and electrolyte balance in these clients. Choice A is incorrect because clients with renal failure often have fluid restrictions. Choice B is incorrect as high-sodium foods can worsen fluid retention in clients with renal failure. Choice D is incorrect because dietary restrictions are important in managing chronic renal failure, and eating whatever one wants can lead to further complications.

2. The nurse is preparing to administer intravenous gentamicin to an infant through an intermittent needle. The nurse notes that the infant has not had a wet diaper for several hours. The nurse will perform which action?

• A. Administer the medication and give the infant extra oral fluids.
• B. Contact the provider to request adding intravenous fluids when giving the medication.
• C. Give the medication and obtain a serum peak drug level 45 minutes after the dose.
• D. Hold the dose and contact the provider to request a serum trough drug level.

Correct answer: D

Rationale: In this scenario, the infant not having a wet diaper for several hours indicates a potential decrease in urine output, which can be a sign of nephrotoxicity related to gentamicin. The correct action for the nurse is to hold the dose and contact the provider to request a serum trough drug level. This is important to monitor the drug levels and ensure that they are not reaching toxic levels. Administering the medication without addressing the decreased urine output could potentially lead to further nephrotoxicity. Contacting the provider to add intravenous fluids or obtaining a serum peak drug level are not the most appropriate actions in this situation as the priority is to assess for potential nephrotoxicity and ensure patient safety.

3. Which of the following assessments is the most important for a patient receiving IV potassium?

• A. Respiratory rate
• B. Heart rate
• C. Blood pressure
• D. Oxygen saturation

Correct answer: C

Rationale: The most important assessment for a patient receiving IV potassium is monitoring blood pressure. IV potassium can cause significant changes in cardiac function, leading to adverse effects such as arrhythmias and cardiac arrest. While respiratory rate, heart rate, and oxygen saturation are important parameters to monitor in clinical practice, blood pressure takes precedence in patients receiving IV potassium due to its direct impact on cardiovascular function. Changes in blood pressure can be an early indicator of potassium-induced cardiac complications, making it crucial to monitor closely during administration.

4. A client with a completed ischemic stroke has a blood pressure of 180/90 mm Hg. Which action should the nurse implement?

• A. Position the head of the bed (HOB) flat.
• B. Withhold intravenous fluids.
• C. Administer a bolus of IV fluids.
• D. Give an antihypertensive medication.

Correct answer: D

Rationale: In a client with a completed ischemic stroke, an elevated blood pressure like 180/90 mm Hg requires immediate intervention to prevent further damage. Giving an antihypertensive medication is essential to reduce the risk of recurrent stroke or complications related to hypertension. Positioning the head of the bed flat, withholding IV fluids, or administering a bolus of IV fluids are not appropriate actions for managing elevated blood pressure in this scenario and may not address the underlying cause of the hypertension or prevent potential complications.

5. An emergency department nurse assesses a client with a history of urinary incontinence who presents with extreme dry mouth, constipation, and an inability to void. Which question should the nurse ask first?

• A. Are you drinking plenty of water?
• B. What medications are you taking?
• C. Have you tried laxatives or enemas?
• D. Has this type of thing ever happened before?

Correct answer: B

Rationale: In this scenario, the client's symptoms of dry mouth, constipation, and inability to void are indicative of anticholinergic side effects, which can be caused by medications like propantheline (Pro-Banthine) commonly used to treat incontinence. The first question the nurse should ask is about the client's medications to determine if they are taking anticholinergic drugs. This information is crucial as it can help differentiate between a simple side effect or a potential overdose. Asking about water intake (Choice A) may be relevant later but is not the priority in this situation. Questioning about laxatives or enemas (Choice C) and past occurrences (Choice D) are not as pertinent initially as identifying the client's current medication status.

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