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. A patient is being treated for shock after a motor vehicle accident. The provider orders 6% dextran 75 to be given intravenously. The nurse should expect which outcome as the result of this infusion?

• A. Decreased urine output
• B. Improved blood oxygenation
• C. Increased interstitial fluid
• D. Stabilization of heart rate and blood pressure

Correct answer: D

Rationale: 6% Dextran 75 is a high molecular-weight colloidal solution used to treat shock from burns or trauma. Colloids like 6% dextran 75 are plasma expanders that help increase blood volume, leading to improved heart rate and blood pressure stabilization. The infusion of plasma expanders does not typically decrease urine output. It primarily aims to stabilize circulation rather than affect blood oxygenation or increase interstitial fluid levels.

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. The healthcare provider is assessing a client undergoing peritoneal dialysis. Which of the following findings should be reported immediately to the physician?

• A. Clear dialysate outflow.
• B. Clear dialysate inflow.
• C. Cloudy dialysate outflow.
• D. Increased blood pressure.

Correct answer: C

Rationale: Cloudy dialysate outflow should be reported immediately to the physician as it is a concerning sign of peritonitis, a severe infection of the peritoneum. Peritonitis is a serious complication of peritoneal dialysis that requires prompt medical intervention to prevent further complications. Clear dialysate outflow and inflow are normal findings in peritoneal dialysis and do not indicate an immediate need for intervention. Increased blood pressure, while important to monitor, is not directly related to peritoneal dialysis and would not be the priority over the potentially life-threatening complication of peritonitis.

5. The nurse is monitoring a client with chronic renal failure who is receiving hemodialysis. The nurse should report which of the following findings immediately?

• A. Clear dialysate outflow.
• 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: The correct answer is B. Weight gain of 2 lbs (0.9 kg) since the last treatment is concerning in a client undergoing hemodialysis with chronic renal failure as it may indicate fluid overload. This finding requires immediate reporting and intervention to prevent complications such as fluid retention, pulmonary edema, or exacerbation of heart failure. Choices A, C, and D are not findings that require immediate attention in this context. Clear dialysate outflow is a normal finding during hemodialysis, a blood pressure of 130/80 mm Hg is within a normal range for many clients, and a pulse rate of 72 bpm is also within the expected range for most individuals.

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