Nursing Elites

1. A nurse is caring for a client who has chronic kidney disease and reports nausea. The nurse should identify that this client is at risk for which of the following imbalances?

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

Correct answer: B

Rationale: The correct answer is B: Metabolic acidosis. Clients with chronic kidney disease are at risk for metabolic acidosis because the kidneys are unable to effectively excrete acids, leading to an accumulation of acid in the body. This metabolic imbalance can result in symptoms like nausea. Choices A, C, and D are incorrect. Metabolic alkalosis is not typically associated with chronic kidney disease. Respiratory alkalosis is more commonly seen in conditions such as hyperventilation. Respiratory acidosis, on the other hand, is often linked to conditions affecting the lungs or respiratory system, not primarily kidney disease.

2. A nurse is caring for a client who has DVT. Which of the following instructions should the nurse include in the plan of care?

• A. Limit the client's fluid intake to 1500 mL per day
• B. Avoid massaging the affected extremity to relieve pain
• C. Avoid applying cold packs to the client's affected extremity
• D. Elevate the client's affected extremity when in bed

Correct answer: D

Rationale: The correct instruction for a client with DVT is to elevate the affected extremity when in bed. Elevation helps reduce swelling by promoting venous return. Limiting fluid intake could lead to dehydration and is not recommended. Massaging the affected extremity can dislodge a clot, leading to serious complications. Applying cold packs can cause vasoconstriction and should be avoided in DVT.

3. A nurse is teaching a client who is at 10 weeks gestation about the amniocentesis procedure. Which of the following statements should the nurse make?

• A. This test will confirm whether your baby has a genetic disorder.
• B. Amniocentesis is used to assess your baby's lung maturity.
• C. You should not feel any pain during this procedure.
• D. This test will assess the amount of amniotic fluid around your baby.

Correct answer: A

Rationale: The correct answer is A because amniocentesis is a procedure that confirms genetic disorders by analyzing the amniotic fluid surrounding the baby. Choice B is incorrect because amniocentesis is not used to assess lung maturity. Choice C is incorrect because some discomfort or pain may be felt during the procedure. Choice D is incorrect because amniocentesis does not primarily assess the amount of amniotic fluid around the baby.

4. A nurse is assessing a client who has a chest tube. Which of the following findings should the nurse report to the provider?

• A. Constant bubbling in the water seal chamber.
• B. Intermittent bubbling in the suction control chamber.
• C. Tidaling in the water seal chamber.
• D. Drainage of 75 mL in the first 24 hours.

Correct answer: A

Rationale: The correct answer is A: Constant bubbling in the water seal chamber. Constant bubbling in the water seal chamber can indicate an air leak, which compromises the integrity of the chest tube system and should be reported to the provider for immediate intervention. Choices B, C, and D are incorrect. Intermittent bubbling in the suction control chamber is an expected finding indicating that the system is working appropriately. Tidaling in the water seal chamber is a normal fluctuation of fluid level with inspiration and expiration, indicating that the system is functioning correctly. Drainage of 75 mL in the first 24 hours is within the expected range for chest tube drainage and does not require immediate reporting unless accompanied by other concerning symptoms.

5. A nurse is assessing a client who is receiving furosemide for heart failure. Which of the following findings is the priority to report to the provider?

• A. Blood pressure of 98/58 mm Hg
• B. Urine output of 50 mL/hr
• C. Serum potassium level of 3.2 mEq/L
• D. Weight loss of 0.5 kg (1.1 lb) in 24 hours

Correct answer: C

Rationale: The correct answer is C. A serum potassium level of 3.2 mEq/L indicates hypokalemia, a potential complication of furosemide therapy, and should be reported immediately. Hypokalemia can lead to serious cardiac dysrhythmias. Choices A, B, and D are important assessments but are not as critical as managing serum potassium levels in a client receiving furosemide for heart failure.

Similar Questions