Nursing Elites

1. A nurse assesses a client who is recovering from a radical nephrectomy for renal cell carcinoma. The nurse notes that the client’s blood pressure has decreased from 134/90 to 100/56 mm Hg and urine output is 20 mL for this past hour. Which action should the nurse take?

• A. Position the client to lay on the surgical incision.
• B. Measure the specific gravity of the client’s urine.
• C. Administer intravenous pain medications.
• D. Assess the rate and quality of the client’s pulse.

Correct answer: D

Rationale: The nurse should first fully assess the client for signs of volume depletion and shock, and then notify the provider. The radical nature of the surgery and the proximity of the surgery to the adrenal gland put the client at risk for hemorrhage and adrenal insufficiency. Hypotension is a clinical manifestation associated with both hemorrhage and adrenal insufficiency. Hypotension is particularly dangerous for the remaining kidney, which must receive adequate perfusion to function effectively. Re-positioning the client, measuring specific gravity, and administering pain medication would not provide data necessary to make an appropriate clinical decision, nor are they appropriate interventions at this time.

2. The nurse is providing discharge teaching to a client with coronary artery disease (CAD). Which of the following statements by the client indicates a need for further teaching?

• A. I will take my medication only when I have chest pain.
• B. I will follow a heart-healthy diet and exercise regularly.
• C. I will avoid smoking and limit alcohol intake.
• D. I will contact my doctor if I experience chest pain or shortness of breath.

Correct answer: A

Rationale: The statement indicates a misunderstanding because medication for CAD should be taken as prescribed, not only when chest pain occurs.

3. What is the primary action of insulin in the body?

• A. To lower blood pressure.
• B. To promote the absorption of glucose into cells.
• C. To increase blood glucose levels.
• D. To decrease blood glucose levels.

Correct answer: B

Rationale: The correct answer is B: To promote the absorption of glucose into cells. Insulin facilitates the uptake of glucose by cells, thereby decreasing blood glucose levels. Choice A is incorrect as insulin does not directly affect blood pressure. Choice C is inaccurate as insulin works to lower, not increase, blood glucose levels. Choice D is incorrect because insulin's primary role is to lower, not increase, blood glucose levels by promoting glucose uptake into cells.

4. A client is undergoing hemodialysis. The client’s blood pressure at the beginning of the procedure was 136/88 mm Hg, and now it is 110/54 mm Hg. What actions should the nurse perform to maintain blood pressure? (Select all that apply.)

• A. Adjust the rate of extracorporeal blood flow.
• B. Place the client in the Trendelenburg position.
• C. Administer a 250-mL bolus of normal saline.
• D. All of the above

Correct answer: D

Rationale: During hemodialysis, a drop in blood pressure can occur due to fluid removal. To maintain blood pressure, the nurse should consider adjusting the rate of extracorporeal blood flow to optimize fluid removal without causing hypotension. Placing the client in the Trendelenburg position can help improve venous return and cardiac output. Administering a bolus of normal saline can help increase intravascular volume and support blood pressure. Therefore, all the actions listed in choices A, B, and C are appropriate measures to maintain blood pressure during hemodialysis. Choice D, 'All of the above,' is the correct answer as it encompasses all the relevant actions to address the dropping blood pressure effectively. Choices A, B, and C, when implemented together, can help manage hypotension during hemodialysis.

5. The nurse empties the nasogastric suction collection canister of a client who had a bowel resection the previous day and notes that 1000 ml of gastric secretions were collected in the last 4 hours. What condition is the client at risk for developing?

• A. Metabolic alkalosis
• B. Hyperkalemia
• C. Metabolic acidosis
• D. Hypoglycemia

Correct answer: A

Rationale: The correct answer is A: Metabolic alkalosis. Loss of gastric secretions, which contain stomach acid, can lead to metabolic alkalosis. Excessive loss of acid results in an increase in the blood pH, leading to alkalosis. Hyperkalemia (B) is an elevated potassium level and is not directly related to the loss of gastric secretions. Metabolic acidosis (C) is an acid-base imbalance characterized by low pH and bicarbonate levels, which is the opposite of what would occur with the loss of gastric secretions. Hypoglycemia (D) is low blood sugar and is not typically associated with the scenario described in the question.

Similar Questions