Nursing Elites

1. A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first?

• A. Inform the client that the blood pressure is high and that the reading needs to be verified by another nurse.
• B. Contact the healthcare provider to report the reading and obtain a prescription for an antihypertensive medication.
• C. Replace the cuff with a larger one to ensure a proper fit for the client and increase arm comfort.
• D. Compare the current reading with the client's previously documented blood pressure readings.

Correct answer: D

Rationale: The correct action for the nurse to take first in this situation is to compare the current blood pressure reading with the client's previously documented readings. This comparison will provide valuable information about what is normal for this specific client, helping to determine if the current reading represents a significant change or if it falls within the client's usual range. By reviewing the client's past readings, the nurse can assess trends, variations, and if the current reading is an isolated high value or part of a pattern, guiding appropriate decision-making. Informing the client about the high reading (Choice A) or contacting the healthcare provider for medication (Choice B) should come after assessing the client's history. Replacing the cuff (Choice C) is not necessary at this point and does not address the immediate need to compare the readings for appropriate intervention.

2. A client with a diagnosis of renal failure is receiving hemodialysis. Which assessment finding should the nurse report to the healthcare provider immediately?

• A. The client's blood pressure is 130/80 mm Hg.
• B. The client gains 1 kg in 24 hours.
• C. The client's potassium level is 5.5 mEq/L.
• D. The client's weight decreases by 0.5 kg in 24 hours.

Correct answer: C

Rationale: A potassium level of 5.5 mEq/L (C) is elevated and concerning in a client with renal failure receiving hemodialysis, as it can lead to life-threatening cardiac arrhythmias. Monitoring blood pressure (A), weight gain (B), and weight loss (D) are essential in clients on hemodialysis, but an elevated potassium level poses an immediate risk that requires prompt intervention.

3. A client with a diagnosis of hyperkalemia is receiving sodium polystyrene sulfonate (Kayexalate). Which laboratory value should the nurse monitor to evaluate the effectiveness of this medication?

• A. Serum sodium level.
• B. Serum potassium level.
• C. Serum calcium level.
• D. Serum glucose level.

Correct answer: B

Rationale: The correct answer is B: Serum potassium level. Sodium polystyrene sulfonate (Kayexalate) is used to treat hyperkalemia by exchanging sodium ions for potassium ions in the intestines, leading to potassium removal from the body. Monitoring the serum potassium level allows the nurse to assess the effectiveness of this medication in lowering the elevated potassium levels. Serum sodium (A), calcium (C), and glucose (D) levels are not directly impacted by the action of sodium polystyrene sulfonate.

4. After hemodialysis, a client with a history of chronic renal failure has just returned to the unit. What is the most important assessment for the nurse to make?

• A. Auscultate the client's lung sounds.
• B. Assess the client's blood pressure.
• C. Monitor the client's weight.
• D. Check the client's fistula for bruit and thrill.

Correct answer: D

Rationale: The most crucial assessment for the nurse to make after hemodialysis in a client with chronic renal failure is to check the client's fistula for bruit and thrill (D). This assessment is essential to ensure the patency of the fistula and adequate blood flow. Auscultating lung sounds (A), assessing blood pressure (B), and monitoring weight (C) are important assessments but are secondary to evaluating the fistula. Checking the fistula is vital as it directly impacts the effectiveness of the client's dialysis treatment and the patency of the vascular access, ensuring successful dialysis sessions.

5. After receiving written and verbal instructions from a clinic nurse about a newly prescribed medication, a client asks the nurse what to do if questions arise about the medication after getting home. How should the nurse respond?

• A. Provide the client with a list of reputable Internet sites that answer frequently asked questions about medications.
• B. Advise the client to obtain a current edition of a drug reference book from a local bookstore or library.
• C. Reassure the client that information about the medication is included in the written instructions.
• D. Encourage the client to call the clinic nurse or health care provider if any questions arise.

Correct answer: D

Rationale: To ensure safe medication use, the nurse should encourage the client to call the clinic nurse or health care provider if any questions arise. Direct communication with healthcare professionals involved in the client's care is crucial to address any concerns promptly and accurately, ensuring the client's safety and understanding of the prescribed medication.

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