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. A client is getting out of bed for the first time since surgery. The client complains of dizziness after the nurse raises the head of the bed. Which of the following actions should the nurse take first?

• A. Checking the client’s blood pressure
• B. Checking the oxygen saturation level
• C. Having the client take some deep breaths
• D. Lowering the head of the bed slowly until the dizziness is relieved

Correct answer: D

Rationale: When a client experiences dizziness after being positioned upright for the first time post-surgery, the initial action the nurse should take is to lower the head of the bed slowly until the dizziness subsides. This maneuver helps alleviate the dizziness by allowing the body to adapt gradually to the change in position. Subsequently, the nurse should assess the client's pulse and blood pressure. Checking the blood pressure is essential to evaluate the circulatory status and rule out orthostatic hypotension as a cause of dizziness. Checking the oxygen saturation level and having the client take deep breaths are not the priority in this scenario as the primary concern is addressing the circulatory issue causing dizziness, not a respiratory problem.

3. A nurse is conducting an assessment of a client who underwent thoracentesis of the right side of the chest 3 hours ago. Which findings does the nurse report to the physician? Select all that apply.

• A. Unequal chest expansion
• B. Pulse rate of 82 beats/min
• C. Respiratory rate of 22 breaths/min
• D. Diminished breath sounds in the right lung

Correct answer: A

Rationale: After thoracentesis, the nurse should assess the client for signs of pneumothorax, which include increased respiratory rate, dyspnea, retractions, unequal chest expansion, diminished breath sounds, and cyanosis. Unequal chest expansion is a key sign of pneumothorax due to the accumulation of air in the pleural space, causing the affected lung to collapse partially. Pulse rate and respiratory rate within normal ranges, like in choices B and C, are not the priority findings to report in this situation. Diminished breath sounds in the right lung could be expected after thoracentesis and may not necessarily indicate a complication like pneumothorax, making choice D less urgent to report.

4. A client with chronic renal failure is prescribed a low-protein diet. The nurse should explain to the client that the purpose of this diet is to:

• A. Prevent fluid overload.
• B. Reduce the workload on the kidneys.
• C. Prevent dehydration.
• D. Maintain electrolyte balance.

Correct answer: B

Rationale: The correct answer is B: 'Reduce the workload on the kidneys.' A low-protein diet is prescribed for clients with chronic renal failure to decrease the production of urea and other nitrogenous wastes, which can accumulate in the body when the kidneys are not functioning properly. This reduction in protein intake helps to lessen the burden on the kidneys, as they may have difficulty in filtering and excreting waste products. Choice A is incorrect because fluid overload is more related to restrictions in fluid intake rather than protein intake. Choice C is incorrect as a low-protein diet does not directly prevent dehydration. Choice D is incorrect because while electrolyte balance is essential in renal failure, the primary purpose of a low-protein diet is to reduce the workload on the kidneys by limiting the production of waste products.

5. The client is receiving teletherapy radiation for a malignant tumor. Which instruction regarding skin care of the portal site should the nurse provide?

• A. Protect the skin of the radiation portal site from sunlight exposure
• B. Apply moisturizing lotions daily to the radiation portal site
• C. Avoid washing the skin inside the radiation portal site
• D. Remove the ink marks of the portal after each radiation treatment

Correct answer: A

Rationale: Protecting the skin from sunlight exposure is crucial to prevent radiation burns and additional skin damage at the treatment site. Sun exposure can exacerbate skin reactions caused by radiation therapy. Applying moisturizing lotions daily may introduce foreign substances or irritants to the treated area, leading to potential complications. Washing the skin inside the radiation portal site is important for maintaining cleanliness and preventing infections. Removing the ink marks after each treatment is unnecessary and may cause unnecessary skin irritation and trauma.

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