Nursing Elites

1. Which of the following is a primary intervention for a patient with sepsis?

• A. Administering antibiotics
• B. Administering IV fluids
• C. Administering antipyretics
• D. Monitoring blood cultures

Correct answer: D

Rationale: Monitoring blood cultures is a primary intervention for a patient with sepsis because it helps identify the causative organism, which is crucial in guiding appropriate antibiotic therapy. Administering antibiotics (Choice A) is important in treating sepsis but is considered a secondary intervention. Administering IV fluids (Choice B) is also crucial for sepsis management to restore perfusion and hemodynamic stability. Administering antipyretics (Choice C) may help reduce fever, but it is not a primary intervention for managing sepsis.

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

• A. Temperature of 98.6°F (37°C).
• 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: Weight gain between dialysis sessions can indicate fluid overload, a common complication in clients with chronic renal failure. This can lead to complications such as hypertension, pulmonary edema, and heart failure. A normal temperature, blood pressure, and pulse rate are expected findings in this scenario and would not typically indicate a complication of hemodialysis treatment.

3. The nurse is caring for a client who is receiving an IV infusion of normal saline and notices that the infusion is not flowing. The insertion site is not inflamed or swollen. What should the nurse do first?

• A. Check the tubing for kinks or obstructions.
• B. Increase the flow rate to improve the infusion.
• C. Reinsert the IV catheter in another vein.
• D. Call the physician for further instructions.

Correct answer: A

Rationale: The correct first action for the nurse to take when an IV infusion is not flowing despite a normal insertion site is to check the tubing for kinks or obstructions. This step is crucial to ensure that there are no preventable issues impeding the flow of the IV solution. Increasing the flow rate without addressing potential obstructions could lead to complications such as infiltration. Reinserting the IV catheter in another vein should only be considered after ruling out tubing issues. Calling the physician for further instructions is not necessary at this stage as troubleshooting the tubing should be the initial intervention.

4. A client is admitted with acute kidney injury (AKI) and a urine output of 2000 mL/day. What is the major concern of the nurse regarding this client’s care?

• A. Edema and pain
• B. Electrolyte and fluid imbalance
• C. Cardiac and respiratory status
• D. Mental health status

Correct answer: B

Rationale: The major concern for a client admitted with acute kidney injury (AKI) and a high urine output of 2000 mL/day is electrolyte and fluid imbalance. In AKI, there may be an inflammatory cause leading to proteins entering the glomerulus, resulting in fluid being held in the filtrate and causing polyuria. Electrolyte loss and fluid balance are critical to monitor and manage in AKI cases. Edema and pain are not typically associated with fluid loss. While changes in cardiac, respiratory, and mental health status can occur if electrolyte imbalance is not addressed, the primary focus should be on managing electrolyte and fluid balance to prevent further complications.

5. The nurse is obtaining a health history from a new client who has a history of kidney stones. Which statement by the client indicates an increased risk for renal calculi?

• A. Eats a vegetarian diet with cheese 2 to 3 times a day
• B. Experiences additional stress since adopting a child
• C. Jogs more frequently than usual daily routine
• D. Drinks several bottles of carbonated water daily

Correct answer: D

Rationale: The correct answer is D. Drinking several bottles of carbonated water daily may contribute to renal calculi formation due to the high mineral content. Carbonated drinks can increase the risk of kidney stones due to their high levels of phosphoric acid and caffeine, which can lead to the formation of crystals in the urine. Choices A, B, and C are less likely to directly contribute to an increased risk of renal calculi compared to the excessive consumption of carbonated water.

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