Nursing Elites

1. The nurse observes an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a transurethral resection of the prostate (TURP). What is the best initial nursing action?

• A. Provide additional oral fluid intake
• B. Measure the client's intake and output
• C. Increase the flow of the bladder irrigation
• D. Administer a PRN dose of an antispasmodic agent

Correct answer: C

Rationale: The best initial nursing action when observing an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation post-TURP is to increase the flow of the bladder irrigation. This action helps prevent blood clots from obstructing the catheter, ensuring effective drainage and promoting client comfort. Providing additional oral fluid intake (Choice A) is important for overall hydration but may not directly address the issue of blood clots in the drainage tubing. Measuring the client's intake and output (Choice B) is a routine nursing assessment that may not directly address the immediate concern of blood clots obstructing the catheter. Administering a PRN dose of an antispasmodic agent (Choice D) is not the best initial action as it does not directly address the issue of blood clots in the drainage tubing.

2. After educating a client with hypertension secondary to renal disease, the nurse assesses the client’s understanding. Which statement made by the client indicates a need for additional teaching?

• A. I can prevent more damage to my kidneys by managing my blood pressure.
• B. If I have increased urination at night, I need to drink less fluid during the day.
• C. I need to see the registered dietitian to discuss limiting my protein intake.
• D. It is important that I take my antihypertensive medications as directed.

Correct answer: B

Rationale: Choice B is incorrect because the client should not restrict fluids during the day due to increased urination at night. Clients with renal disease may be prescribed fluid restrictions, and they should be thoroughly assessed for potential dehydration. To decrease increased nocturnal voiding, clients should consume fluids earlier in the day. Choices A, C, and D are correct statements. Managing blood pressure is crucial to slow the progression of renal dysfunction. Limiting protein intake is important in renal disease management, and clients should be referred to a dietitian as needed. Taking antihypertensive medications as directed is essential for blood pressure control.

3. A client is hospitalized in the oliguric phase of acute kidney injury (AKI) and is receiving tube feedings. The nurse is teaching the client’s spouse about the kidney-specific formulation for the enteral solution compared to standard formulas. What components should be discussed in the teaching plan? (Select all that apply.)

• A. Lower sodium
• B. Lower potassium
• C. Higher phosphorus
• D. A & B

Correct answer: D

Rationale: In the oliguric phase of acute kidney injury (AKI), clients may require tube feedings with kidney-specific formulas. These formulations are lower in sodium and potassium, which are crucial considerations due to impaired kidney function. Higher phosphorus content is not a feature of kidney-specific formulations for AKI. Therefore, options A and B (lower sodium and lower potassium) should be discussed in the teaching plan. Option C, higher phosphorus, is incorrect as kidney-specific formulas are not intended to be higher in phosphorus content for AKI patients.

4. Laboratory findings indicate that a client's serum potassium level is 2.5 mEq/L. What action should the nurse take?

• A. Inform the healthcare provider of the need for potassium replacement.
• B. Prepare to administer a glucose-insulin-potassium replacement.
• C. Change the plan of care to include hourly urinary output measurement.
• D. Instruct the client to increase daily intake of potassium-rich foods.

Correct answer: A

Rationale: A serum potassium level of 2.5 mEq/L is critically low, indicating severe hypokalemia. The immediate action the nurse should take is to inform the healthcare provider of the need for potassium replacement. Option B, preparing to administer glucose-insulin-potassium replacement, is not the first-line intervention; it may be considered in specific situations but requires a healthcare provider's prescription. Option C, changing the plan of care to include hourly urinary output measurement, is not the priority when managing critically low potassium levels. Option D, instructing the client to increase daily intake of potassium-rich foods, is not appropriate in this acute situation where immediate intervention is needed to address the dangerously low potassium level.

5. The healthcare provider is assessing a client with chronic renal failure who is receiving peritoneal dialysis. Which of the following findings would indicate a complication of the treatment?

• A. Clear dialysate outflow.
• B. Cloudy dialysate outflow.
• C. Decreased urine output.
• D. Increased blood pressure.

Correct answer: B

Rationale: Cloudy dialysate outflow is a sign of peritonitis, a serious complication of peritoneal dialysis that requires immediate medical attention. Peritonitis, an infection of the peritoneum, the lining of the abdominal cavity, can lead to severe complications if not treated promptly. Clear dialysate outflow is an expected finding in peritoneal dialysis, indicating proper functioning of the process. Decreased urine output is common in clients with renal failure due to impaired kidney function. Increased blood pressure may be present in renal failure but is not a direct complication of peritoneal dialysis.

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