Nursing Elites

1. A client is receiving a low dose of dopamine (Intropin) IV for the treatment of hypotension. Which indicator reflects that the medication is having the desired effect?

• A. Increased heart rate
• B. Increased urinary output
• C. Increased blood pressure
• D. Increased respiratory rate

Correct answer: C

Rationale: Increased blood pressure is the desired effect of administering dopamine (Intropin) to treat hypotension. Dopamine acts by stimulating adrenergic receptors, leading to vasoconstriction and increased cardiac output. This results in an elevation of blood pressure. Choices A, B, and D are incorrect as they do not directly reflect the therapeutic action of dopamine in treating hypotension. Increased heart rate may indicate the body compensating for low blood pressure, increased urinary output is more related to kidney function, and increased respiratory rate is often seen in response to respiratory issues, not the action of dopamine on hypotension.

2. A child with Leukemia is admitted for chemotherapy, and the nursing diagnosis, altered nutrition, less than body requirements related to anorexia, nausea, vomiting is identified. Which intervention should the nurse include in this child's plan of care?

• A. Allow the child to eat foods desired and tolerated
• B. Restrict foods brought from fast food restaurants
• C. Recommend eating the same foods as siblings eat at home
• D. Encourage a variety of large portions of food at every meal

Correct answer: A

Rationale: The correct intervention for a child with Leukemia undergoing chemotherapy and experiencing altered nutrition, less than body requirements due to anorexia, nausea, and vomiting is to allow the child to eat foods desired and tolerated. This intervention helps improve the child's nutrition intake during chemotherapy. Choice B is incorrect because restricting foods may further limit the child's nutritional intake. Choice C is incorrect because recommending eating the same foods as siblings may not align with the child's preferences or needs during treatment. Choice D is incorrect as encouraging large portions of food at every meal may overwhelm the child and be counterproductive to their nutritional needs.

3. A client who is 12-hours post-op following a left hip replacement has an indwelling urinary catheter. The nurse determines that the client's urinary output is 60 ml in the past 3 hours. What action should the nurse take first?

• A. Assess the client's vital signs
• B. Irrigate the catheter with 30 ml of sterile normal saline
• C. Notify the healthcare provider
• D. Replace the catheter with a larger size

Correct answer: A

Rationale: In a client post-op with low urinary output, the first action the nurse should take is to assess the client's vital signs. Vital signs can provide valuable information about the client's overall condition, fluid status, and potential complications. Assessing the vital signs can help the nurse to determine if the low urine output is indicative of a larger issue that needs immediate attention. Irrigating the catheter with normal saline may be necessary but should not be the first action without assessing the client. Notifying the healthcare provider should follow assessment if there are concerns. Replacing the catheter with a larger size is not indicated solely based on low urinary output and should not be the first action taken.

4. A postoperative client returns to the nursing unit following a ureter lithotomy via a flank incision. Which potential nursing problem has the highest priority when planning nursing care for this client?

• A. Ineffective airway clearance
• B. Altered nutrition less than body requirements
• C. Fluid volume excess
• D. Activity intolerance

Correct answer: A

Rationale: The correct answer is 'Ineffective airway clearance.' Following a ureter lithotomy via a flank incision, the highest priority nursing problem is ensuring the client's airway remains clear. This is crucial for effective breathing and oxygenation. Altered nutrition, fluid volume excess, and activity intolerance are important to address but are of lower priority compared to maintaining a clear airway postoperatively.

5. A client is leaving the hospital against medical advice (AMA) and voluntarily signs the AMA form. Which nursing action is essential prior to the client leaving?

• A. Remove the client's peripheral IV access
• B. Administer requested pain relief medication
• C. Obtain the client's neurological vital signs
• D. Provide the client with the hospital's phone number

Correct answer: A

Rationale: Removing the client's peripheral IV access is essential before the client leaves against medical advice to prevent complications such as infection, thrombosis, or bleeding. Administering pain relief medication (choice B) can be important but not essential at this point. Obtaining neurological vital signs (choice C) is not specifically required before the client leaves. Providing the client with the hospital's phone number (choice D) may be helpful but is not as essential as ensuring the safe removal of IV access.

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