Nursing Elites

1. A client who has undergone pleural biopsy is being monitored by a nurse. Which finding indicates a potential complication for the client?

• A. Warm, dry skin
• B. Mild pain at the biopsy site
• C. Complaints of shortness of breath
• D. Capillary refill time of less than 3 seconds

Correct answer: C

Rationale: Complaints of shortness of breath are a concerning finding post-pleural biopsy, as they may indicate a complication such as a pneumothorax or hemothorax. Shortness of breath can be a sign of respiratory distress that requires immediate attention. Warm, dry skin, mild pain at the biopsy site, and a capillary refill time of less than 3 seconds are not typically associated with immediate complications following a pleural biopsy. Warm, dry skin may be a normal finding, mild pain can be expected at the biopsy site, and a capillary refill time of less than 3 seconds is within normal limits.

2. The client is planning care for a client who is receiving hemodialysis. Which of the following interventions should be included in the plan of care?

• A. Administer anticoagulants to prevent clot formation.
• B. Monitor the client for signs of infection.
• C. Provide the client with a high-protein diet.
• D. Encourage the client to drink at least 2 liters of fluid daily.

Correct answer: B

Rationale: Monitoring for signs of infection is crucial in clients receiving hemodialysis because they are at an increased risk of infection due to the invasive nature of the procedure. Administering anticoagulants is not typically a part of the routine care for clients undergoing hemodialysis unless specifically prescribed. While a high-protein diet may be beneficial for some clients, it is not a specific intervention related to hemodialysis. Encouraging fluid intake must be individualized based on the client's fluid status and should not be a generalized recommendation for all clients receiving hemodialysis.

3. The nurse is caring for several patients who are receiving antibiotics. Which order will the nurse question?

• A. Azithromycin (Zithromax) 500 mg IV in 500 mL of fluid
• B. Azithromycin (Zithromax) 500 mg PO once daily
• C. Erythromycin 300 mg IM QID
• D. Erythromycin 300 mg PO QID

Correct answer: C

Rationale: The nurse should question the order for Erythromycin 300 mg IM QID. Erythromycin and other macrolides should not be given intramuscularly because they cause painful tissue irritation. Options A and B are correct routes for Azithromycin, either intravenously or orally. Option D is a correct route for Erythromycin, which is orally.

4. After teaching a client with renal cancer who is prescribed temsirolimus (Torisel), the nurse assesses the client’s understanding. Which statement made by the client indicates a correct understanding of the teaching?

• A. I will take this medication with food and plenty of water.
• B. I shall keep my appointment at the infusion center each week.
• C. I’ll limit my intake of green leafy vegetables while on this medication.
• D. I must not take this medication if I have an infection or am feeling ill.

Correct answer: B

Rationale: The correct answer is B. Temsirolimus, also known as Torisel, is administered as a weekly intravenous infusion. This medication blocks protein needed for cell division, inhibiting cell cycle progression. It is not taken orally, so there is no need to take it with food or water. Keeping the weekly infusion center appointment is crucial for the client to receive the prescribed treatment effectively. Choice A is incorrect as temsirolimus is not taken with food or water. Choice C is incorrect because there is no need to limit the intake of green leafy vegetables while on this medication. Choice D is incorrect as having an infection or feeling ill does not prohibit the use of temsirolimus.

5. A client is recovering from a closed percutaneous kidney biopsy and reports increased pain from 3 to 10 on a scale of 0 to 10. Which action should the nurse take first?

• A. Reposition the client on the operative side.
• B. Administer the prescribed opioid analgesic.
• C. Assess the pulse rate and blood pressure.
• D. Examine the color of the client’s urine.

Correct answer: C

Rationale: An abrupt increase in pain following a percutaneous kidney biopsy may indicate internal hemorrhage. Assessing the client's pulse rate and blood pressure is crucial as changes in vital signs can be indicative of hemorrhage. This assessment is essential in determining the client's hemodynamic status and the need for immediate intervention. Repositioning the client, administering pain medication, or checking urine color are not the priority actions in this situation and may delay necessary interventions for potential hemorrhage.

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