Nursing Elites

1. After a renal biopsy, which intervention should the nurse include in the post-procedure plan of care?

• A. Restricting fluid intake for the first 24 hours
• B. Periodically testing the urine for occult blood
• C. Avoiding the administration of opioid analgesics
• D. Having the client ambulate in the room and hall for short distances

Correct answer: B

Rationale: After a renal biopsy, it is essential to maintain bed rest and frequently assess the client's vital signs and the puncture site. The nurse should test the urine periodically for occult blood to detect any bleeding, which could be a complication of the procedure. Restricting fluid intake for the first 24 hours is not necessary after a renal biopsy and could potentially lead to dehydration. Avoiding the administration of opioid analgesics is not a standard intervention post-renal biopsy unless contraindicated for a specific reason. Having the client ambulate in the room and hall for short distances is generally not recommended immediately after a renal biopsy due to the need for bed rest to prevent complications.

2. 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.

3. To help minimize the risk of postoperative respiratory complications after a hypophysectomy, during preoperative teaching, the nurse should instruct the client how to:

• A. Use incentive spirometry.
• B. Turn in bed.
• C. Take deep breaths.
• D. Cough.

Correct answer: C

Rationale: The correct answer is to instruct the client on how to take deep breaths. Deep breathing exercises are essential in preventing postoperative respiratory complications like atelectasis by promoting lung expansion. Using incentive spirometry is a more specific and advanced method of promoting deep breathing and lung expansion, making it a better choice than just turning in bed. While turning in bed may help with overall comfort and positioning, it is not as directly related to respiratory complications as deep breathing exercises. Coughing, although important for clearing secretions, is not as effective in preventing atelectasis as deep breathing exercises.

4. During nasotracheal suctioning, which of the following observations should be cause for concern to the nurse? Select all that apply.

• A. The client becomes cyanotic.
• B. Secretions are bloody.
• C. The client gags during the procedure.
• D. Clear to opaque secretions are removed.

Correct answer: C

Rationale: During nasotracheal suctioning, the client gagging during the procedure is a cause for concern as it can indicate discomfort or potential airway obstruction. Cyanosis, bloody secretions, or the removal of clear to opaque secretions are expected observations that the nurse should monitor for, but gagging indicates a need for immediate intervention to ensure the safety and comfort of the client. Cyanosis and bloody secretions can signify oxygenation issues and potential complications, while the removal of secretions is the goal of the suctioning procedure.

5. A client’s baseline vital signs are temperature 98°F oral, pulse 74 beats/min, respiratory rate 18 breaths/min, and blood pressure 124/76 mm Hg. The client suddenly spikes a fever to 103°F. Which of the following respiratory rates would the nurse anticipate as part of the body’s response to the change in client status?

• A. 12 breaths/min
• B. 16 breaths/min
• C. 18 breaths/min
• D. 22 breaths/min

Correct answer: D

Rationale: When a client experiences a fever, there is an increase in body temperature, leading to a higher metabolic rate and oxygen demand. As a result, the respiratory rate typically increases to meet the body's increased oxygen needs. Therefore, in response to the fever spike from 98°F to 103°F, the nurse would anticipate a higher respiratory rate. Choices A, B, and C are incorrect because a decrease in body temperature, not an increase as seen in fever, would lead to a decrease in respiratory rate to conserve energy and oxygen consumption.

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