Nursing Elites

1. A client in the intensive care unit is started on continuous venovenous hemofiltration (CVVH). Which finding should prompt immediate action by the nurse?

• A. Blood pressure of 76/58 mm Hg
• B. Sodium level of 138 mEq/L
• C. Potassium level of 5.5 mEq/L
• D. Pulse rate of 90 beats/min

Correct answer: A

Rationale: The correct answer is A: Blood pressure of 76/58 mm Hg. In a client undergoing continuous venovenous hemofiltration (CVVH), hypotension can be a significant concern if replacement fluid does not adequately maintain blood pressure. The nurse should take immediate action to address hypotension to prevent further complications. The sodium level of 138 mEq/L is within normal range, and a potassium level of 5.5 mEq/L, while slightly elevated, may be expected in a patient with acute kidney injury. A pulse rate of 90 beats/min falls within the normal range and does not typically require immediate intervention in this context.

2. During CPR, when attempting to ventilate a client's lungs, the nurse notes that the chest is not moving. What action should the nurse take first?

• A. Use a laryngoscope to check for a foreign body lodged in the airway.
• B. Reposition the head to ensure that the airway is properly opened.
• C. Turn the client to the side and administer three back blows.
• D. Perform a finger sweep of the mouth to clear any obstructions.

Correct answer: B

Rationale: The most common reason for inadequate lung aeration during CPR is the incorrect positioning of the head, leading to airway obstruction. Therefore, the initial action should be to reposition the head to open the airway properly and attempt to ventilate again. Using a laryngoscope to check for foreign bodies in the airway (Choice A) is not the first step and could delay crucial interventions. Turning the client to the side and administering back blows (Choice C) is not indicated in this scenario as the focus is on ventilating the lungs. Performing a finger sweep of the mouth (Choice D) is not recommended as it may push obstructions further into the airway during CPR.

3. A client admitted with left-sided heart failure has a heart rate of 110 beats per minute and is becoming increasingly dyspneic. Which additional assessment finding by the nurse supports the client's admitting diagnosis?

• A. An enlarged, distended abdomen.
• B. Crackles in the bases of both lungs.
• C. Jugular vein distension.
• D. Peripheral edema.

Correct answer: B

Rationale: The correct answer is B. Crackles in the bases of the lungs are indicative of fluid accumulation, which is common in left-sided heart failure. In left-sided heart failure, the heart is unable to effectively pump blood from the lungs to the rest of the body, leading to a backup of fluid in the lungs. This results in crackles heard on auscultation. Choices A, C, and D are not specific to left-sided heart failure. An enlarged, distended abdomen may indicate ascites or liver congestion. Jugular vein distension is more commonly associated with right-sided heart failure, and peripheral edema is a sign of fluid accumulation in the tissues, which can occur in both types of heart failure but is not as specific to left-sided heart failure as crackles in the lungs.

4. A client is recovering after a nephrostomy tube was placed 6 hours ago. The nurse notes drainage in the tube has decreased from 40 mL/hr to 12 mL over the last hour. Which action should the nurse take?

• A. Document the finding in the client’s record.
• B. Evaluate the tube as working in the hand-off report.
• C. Clamp the tube in preparation for removing it.
• D. Assess the client’s abdomen and vital signs.

Correct answer: D

Rationale: The correct action for the nurse to take in this situation is to assess the client’s abdomen and vital signs. The nephrostomy tube should have a consistent amount of drainage, and a decrease may indicate obstruction. Before notifying the provider, the nurse must assess the client for pain, distention, and changes in vital signs. This assessment is crucial to gather essential information to report accurately. Documenting the finding without further assessment may delay necessary intervention. Evaluating the tube as working in the hand-off report or clamping the tube prematurely are not appropriate actions and could lead to complications if there is an obstruction.

5. A healthcare professional reviews the blood gas results of a client in respiratory distress. The pH is 7.32, and the PCO2 is 50 mm Hg. Which of the following acid-base imbalances does the professional recognize in these findings?

• A. Metabolic acidosis
• B. Metabolic alkalosis
• C. Respiratory acidosis
• D. Respiratory alkalosis

Correct answer: C

Rationale: In respiratory acidosis, the pH is low (<7.35) and the PCO2 is increased (>45 mm Hg). These findings indicate that the client is experiencing respiratory acidosis, a condition where there is an excess of carbon dioxide in the blood due to inadequate ventilation, commonly seen in respiratory distress. Metabolic acidosis (Choice A) is characterized by a low pH and decreased bicarbonate levels, which is not the case in this scenario. Metabolic alkalosis (Choice B) is associated with a high pH and increased bicarbonate levels. Respiratory alkalosis (Choice D) is marked by a high pH and decreased PCO2, opposite to the values presented in the blood gas results of this client.

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