Nursing Elites

1. 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.

2. A client with polycystic kidney disease (PKD is being assessed by a nurse. Which assessment finding should prompt the nurse to immediately contact the healthcare provider?

• A. Flank pain
• B. Periorbital edema
• C. Bloody and cloudy urine
• D. Enlarged abdomen

Correct answer: B

Rationale: Periorbital edema would not typically be associated with polycystic kidney disease (PKD) and could indicate other underlying issues that require immediate attention. Flank pain and an enlarged abdomen are common findings in PKD due to kidney enlargement and displacement of other organs. Bloody or cloudy urine can result from cyst rupture or infection, which are expected in PKD. Therefore, periorbital edema is the most alarming finding in this scenario and warrants prompt notification of the healthcare provider.

3. A CD4+ lymphocyte count is performed on a client infected with HIV. The results of the test indicate a CD4+ count of 450 cells/L. The nurse interprets this test result as indicating:

• A. Improvement in the client
• B. The need for antiretroviral therapy
• C. The need to discontinue antiretroviral therapy
• D. An effective response to the treatment for HIV

Correct answer: B

Rationale: A CD4+ count of 450 cells/L is below the normal range (500-1600 cells/mcL), indicating a decline in immune function in the client. Antiretroviral therapy is recommended when the CD4+ count falls below 500 cells/mcL or below 25%, or when the client displays symptoms of HIV. Therefore, the interpretation of this test result suggests that the client requires antiretroviral therapy to manage the HIV infection. Choices A, C, and D are incorrect because a CD4+ count of 450 cells/L does not signify improvement, discontinuation of therapy, or an effective response to treatment for HIV.

4. A young adult is burned when wearing a shirt that was splashed with lighter fluid and caught on fire while attempting to light a charcoal grill. The client ripped off the shirt immediately, without unbuttoning the sleeves, which caused circumferential burns to both wrists. When the client is admitted, which intervention should the nurse implement first?

• A. Monitor pulse intensity.
• B. Evaluate extremity sensation.
• C. Assess range of motion.
• D. Place sterile bandage on both wrists.

Correct answer: A

Rationale: Monitoring pulse intensity is the priority to ensure circulation is not compromised due to circumferential burns.

5. A client with chronic renal failure is on a low-protein diet. Which of the following is the best response by the nurse when the client asks why this diet is necessary?

• A. It reduces the workload on your kidneys.
• B. It helps prevent the buildup of waste products.
• C. It helps maintain electrolyte balance in your body.
• D. It helps prevent dehydration.

Correct answer: B

Rationale: A low-protein diet is necessary for clients with chronic renal failure because it helps prevent the buildup of waste products, such as urea, in the body. Excess protein can lead to the accumulation of waste products that the compromised kidneys may not effectively filter out, further burdening the already impaired renal function. Choices A, C, and D are incorrect because the primary reason for a low-protein diet in chronic renal failure is to reduce the workload on the kidneys by minimizing the production of waste products that can exacerbate the condition, not specifically to reduce kidney workload, maintain electrolyte balance, or prevent dehydration.

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