Nursing Elites

1. A client is in need of hemodialysis for end-stage renal failure. The physician has inserted an AV fistula. Which of the following nursing interventions is appropriate when caring for this access site?

• A. Assess for clotting in fistula tubing
• B. Apply a dressing over the fistula site
• C. Assess for a bruit or thrill at the site of the fistula
• D. Assess circulation proximal to the fistula site

Correct answer: A

Rationale: When caring for an AV fistula used for hemodialysis, it is important to assess for a bruit (a humming sound) or thrill (a vibrating sensation) at the site of the fistula. These indicate proper blood flow through the fistula, ensuring it is patent and suitable for hemodialysis. Assessing for clotting in fistula tubing (Choice A) is not a routine nursing intervention for AV fistulas. Applying a dressing over the fistula site (Choice B) is not necessary as the site needs to be accessible for hemodialysis. Assessing circulation proximal to the fistula site (Choice D) is important but not specific to caring for the access site of an AV fistula.

2. Which question should the nurse ask the parents of a child suspected of having glomerulonephritis?

• A. Did your child fall off a bike onto the handlebars?
• B. Has the child had persistent nausea and vomiting?
• C. Has the child been itching or had a rash anytime in the last week?
• D. Has the child had a sore throat or a throat infection in the last few weeks?

Correct answer: D

Rationale: Glomerulonephritis refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. Group A ?-hemolytic streptococcal infection is a common cause of glomerulonephritis. Children with glomerulonephritis often develop symptoms after a throat infection caused by streptococcal bacteria. Therefore, asking about a sore throat or throat infection in the last few weeks is crucial to assess the possible link to glomerulonephritis. Choices A, B, and C are not directly associated with the pathophysiology of glomerulonephritis. Asking about falling off a bike, nausea and vomiting, or itching and rash do not provide relevant information for assessing glomerulonephritis in this context.

3. Following a diagnosis of acute glomerulonephritis (AGN) in their 6-year-old child, the parent remarks, 'We just don't know how he caught the disease!' The nurse's response is based on an understanding that

• A. AGN is a streptococcal infection that involves the kidney tubules
• B. The disease is easily transmissible in schools and camps
• C. The illness is usually associated with chronic respiratory infections
• D. It is not 'caught' but is a response to a previous B-hemolytic strep infection

Correct answer: D

Rationale: Acute glomerulonephritis (AGN) is generally considered an immune-complex disease in response to a previous B-hemolytic streptococcal infection, typically occurring 4 to 6 weeks prior. It is not an infectious disease but a noninfectious renal condition. Therefore, the parent's belief that the child 'caught' the disease is inaccurate. Choice A is incorrect because AGN is not a direct streptococcal infection involving the kidney tubules but an immune response to a prior streptococcal infection. Choice B is incorrect as AGN is not easily transmissible in schools and camps. Choice C is incorrect as AGN is not usually associated with chronic respiratory infections but with a previous streptococcal infection.

4. The nurse assesses a patient with chronic obstructive pulmonary disease (COPD) who has been admitted with increasing dyspnea over the last 3 days. Which finding is most important for the nurse to report to the healthcare provider?

• A. Respirations are 36 breaths/minute.
• B. Anterior-posterior chest ratio is 1:1.
• C. Lung expansion is decreased bilaterally.
• D. Hyperresonance to percussion is present.

Correct answer: A

Rationale: The correct answer is 'Respirations are 36 breaths/minute.' An increased respiratory rate is a crucial sign of respiratory distress in patients with COPD, necessitating immediate interventions like oxygen therapy or medications. The other options are common chronic changes seen in COPD patients. Option B, the 'Anterior-posterior chest ratio is 1:1,' is related to the barrel chest commonly seen in COPD due to hyperinflation. Option C, 'Lung expansion is decreased bilaterally,' is expected in COPD due to air trapping. Option D, 'Hyperresonance to percussion is present,' is typical in COPD patients with increased lung volume and air trapping.

5. What nursing intervention demonstrates that the nurse understands the priority nursing diagnosis when caring for oral cancer patients with extensive tumor involvement and/or a high amount of secretions?

• A. The nurse uses a pen pad to communicate with the patient
• B. The nurse provides oral care every 2 hours
• C. The nurse listens for bowel sounds every 4 hours
• D. The nurse suctions as needed and elevates the head of the bed

Correct answer: D

Rationale: The correct answer is to suction as needed and elevate the head of the bed. This intervention is crucial for managing Ineffective Airway Clearance, which is the priority nursing diagnosis in oral cancer patients with extensive tumor involvement and/or a high amount of secretions. Suctioning helps clear secretions that may obstruct the airway, while elevating the head of the bed promotes optimal respiratory function. Providing oral care every 2 hours may be important for overall oral health but is not directly related to addressing the priority diagnosis. Listening for bowel sounds every 4 hours is more relevant to gastrointestinal assessment and not specific to managing airway clearance issues in oral cancer patients.

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