Nursing Elites

1. A 57-year-old male client is scheduled to have a stress-thallium test the following morning and is NPO after midnight. At 0130, he is agitated because he cannot eat and is demanding food. Which response is best for the nurse to provide to this client?

• A. I'm sorry sir, you have a prescription for nothing by mouth from midnight tonight.
• B. I will let you have one cracker, but that is all you can have for the rest of tonight.
• C. What did the healthcare provider tell you about the test you are having tomorrow?
• D. The test you are having tomorrow requires that you have nothing by mouth tonight.

Correct answer: D

Rationale: Being direct and explaining to the client that the test requires him to be NPO, is the most therapeutic statement because the nurse is responding to the client's question and providing him the reason why.

2. Healthcare workers must protect themselves against becoming infected with HIV. The Center for Disease Control has issued guidelines for healthcare workers in relation to protection from HIV. These guidelines include which recommendation?

• A. Place HIV-positive clients in strict isolation and limit visitors.
• B. Wear gloves when coming in contact with the blood or body fluids of any client.
• C. Conduct mandatory HIV testing of those who work with clients with AIDS.
• D. Freeze HIV blood specimens at -70°F to kill the virus.

Correct answer: B

Rationale: The correct answer is B. The CDC guidelines recommend that healthcare workers wear gloves when coming in contact with blood or body fluids from any client since HIV can be infectious before the client becomes aware of their exposure and/or symptomatic. Choice A is incorrect because placing HIV-positive clients in strict isolation and limiting visitors is not a standard practice for HIV infection control. Choice C is incorrect as mandatory HIV testing for those working with AIDS clients is not a CDC recommendation for routine infection control. Choice D is incorrect because freezing HIV blood specimens at -70°F does not kill the virus; HIV can remain infectious even at very low temperatures.

3. A client who has undergone pleural biopsy is being monitored by a nurse. Which finding indicates a potential complication for the client?

• A. Warm, dry skin
• B. Mild pain at the biopsy site
• C. Complaints of shortness of breath
• D. Capillary refill time of less than 3 seconds

Correct answer: C

Rationale: Complaints of shortness of breath are a concerning finding post-pleural biopsy, as they may indicate a complication such as a pneumothorax or hemothorax. Shortness of breath can be a sign of respiratory distress that requires immediate attention. Warm, dry skin, mild pain at the biopsy site, and a capillary refill time of less than 3 seconds are not typically associated with immediate complications following a pleural biopsy. Warm, dry skin may be a normal finding, mild pain can be expected at the biopsy site, and a capillary refill time of less than 3 seconds is within normal limits.

4. 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.

5. A nurse reviews laboratory results for a client with glomerulonephritis. The client’s glomerular filtration rate (GFR) is 40 mL/min as measured by a 24-hour creatinine clearance. How should the nurse interpret this finding? (Select all that apply.)

• A. Excessive GFR
• B. Reduced GFR
• C. Fluid retention and risks for hypertension
• D. Pulmonary edema

Correct answer: B

Rationale: A GFR of 40 mL/min indicates a reduced glomerular filtration rate. In a healthy adult, the normal GFR ranges between 100 and 120 mL/min. A GFR of 40 mL/min signifies a significant reduction, leading to fluid retention and risks for hypertension and pulmonary edema due to excess vascular fluid. Choices A, C, and D are incorrect. Choice A is incorrect as a GFR of 40 mL/min is not excessive but rather reduced. Choices C and D do not directly address the interpretation of GFR but instead describe potential consequences of a reduced GFR.

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