Nursing Elites

1. The healthcare provider is unable to palpate the client's left pedal pulses. Which of the following actions should the healthcare provider take next?

• A. Auscultate the pulses with a stethoscope.
• B. Call the physician.
• C. Use a Doppler ultrasound device.
• D. Inspect the lower left extremity.

Correct answer: C

Rationale: When pedal pulses are not palpable, using a Doppler ultrasound device is the appropriate next step to locate the pulse. Auscultating the pulses with a stethoscope (Choice A) is used for assessing blood flow in arteries above the clavicle, not for pedal pulses. Calling the physician (Choice B) may be necessary at a later stage, but initially, using a Doppler ultrasound device to locate the pulse is more appropriate. Inspecting the lower left extremity (Choice D) can provide visual information but will not help in locating the pedal pulses, making it a less suitable option.

2. The nurse is monitoring a client with chronic renal failure who is receiving hemodialysis. The nurse should report which of the following findings immediately?

• A. Clear dialysate outflow.
• B. Weight gain of 2 lbs (0.9 kg) since the last treatment.
• C. Blood pressure of 130/80 mm Hg.
• D. Pulse rate of 72 bpm.

Correct answer: B

Rationale: The correct answer is B. Weight gain of 2 lbs (0.9 kg) since the last treatment is concerning in a client undergoing hemodialysis with chronic renal failure as it may indicate fluid overload. This finding requires immediate reporting and intervention to prevent complications such as fluid retention, pulmonary edema, or exacerbation of heart failure. Choices A, C, and D are not findings that require immediate attention in this context. Clear dialysate outflow is a normal finding during hemodialysis, a blood pressure of 130/80 mm Hg is within a normal range for many clients, and a pulse rate of 72 bpm is also within the expected range for most individuals.

3. Four hours following surgical repair of a compound fracture of the right ulna, the nurse is unable to palpate the client's right radial pulse. Which action should the nurse take first?

• A. Notify the healthcare provider of the finding immediately.
• B. Complete a neurovascular assessment of the right hand.
• C. Elevate the client's right hand on one or two pillows.
• D. Measure the client's blood pressure and apical pulse rate.

Correct answer: B

Rationale: Completing a neurovascular assessment of the right hand is the priority in this situation. This assessment will help determine the circulation, sensation, and movement of the affected limb, ensuring there are no complications like compartment syndrome or impaired perfusion. Notifying the healthcare provider immediately (Choice A) might be necessary but should come after assessing the client's neurovascular status. Elevating the client's right hand (Choice C) can be helpful in some cases but should not precede a neurovascular assessment. Measuring the client's blood pressure and apical pulse rate (Choice D) is important but not the priority when assessing a potential vascular compromise in the limb.

4. A client with chronic kidney disease starts on hemodialysis. During the first dialysis treatment, the client's blood pressure drops from 150/90 to 80/30. Which action should the nurse take first?

• A. Stop the dialysis treatment
• B. Administer 5% albumin IV
• C. Monitor blood pressure every 45 minutes
• D. Lower the head of the chair and elevate feet

Correct answer: D

Rationale: The initial action the nurse should take when a client's blood pressure drops significantly during hemodialysis is to lower the head of the chair and elevate the feet. This position adjustment helps improve blood flow to the brain and vital organs, assisting in stabilizing blood pressure. Stopping the dialysis treatment immediately may not be necessary if the blood pressure can be managed effectively by position changes. Administering 5% albumin IV is not the first-line intervention for hypotension during dialysis. Monitoring blood pressure every 45 minutes is important but not the immediate action needed to address the significant drop in blood pressure observed during the dialysis session.

5. A client has a chest drainage system in place. The fluid in the water seal chamber rises and falls during inspiration and expiration. The nurse interprets this finding as an indication that:

• A. The tube is patent
• B. There is probably a kink in the tubing
• C. Suction should be added to the system
• D. The client is retaining airway secretions

Correct answer: A

Rationale: The correct answer is A: 'The tube is patent.' When the fluid in the water seal chamber rises and falls during inspiration and expiration, it indicates that the chest tube is patent, allowing for proper drainage. Choice B is incorrect because a kink in the tubing would obstruct the flow of fluid, leading to abnormal fluctuations in the water seal chamber. Choice C is incorrect as adding suction to the system is not indicated based on the described finding. Choice D is incorrect as the rising and falling of fluid in the water seal chamber is not indicative of the client retaining airway secretions.

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