Nursing Elites

1. An adult female client has undergone a routine health screening in the clinic. Which of the following values indicates to the nurse who receives the report of the client’s laboratory work that the client’s hematocrit is normal?

• A. 10%
• B. 22%
• C. 30%
• D. 43%

Correct answer: D

Rationale: The normal hematocrit for an adult female client ranges from 35% to 47%. A hematocrit value of 43% falls within this normal range, indicating normal levels of red blood cells. Choices A, B, and C are low hematocrit values and are considered below the normal range for adult females, signifying potential anemia or other health issues.

2. A nurse performing nasopharyngeal suctioning suddenly notes the presence of bloody secretions. What should the nurse do first?

• A. Continue suctioning to remove the blood
• B. Check the degree of suction being applied
• C. Encourage the client to cough out the bloody secretions
• D. Remove the suction catheter from the client’s nose and begin vigorous suctioning through the mouth

Correct answer: B

Rationale: The correct answer is to check the degree of suction being applied (Choice B). When bloody secretions are encountered during nasopharyngeal suctioning, it is crucial to assess the situation promptly. Checking the degree of suction being applied is the first step as excessive suction pressure may be causing trauma and bleeding. Adjusting the suction pressure may be necessary to prevent further harm. Continuing suctioning to remove the blood (Choice A) or performing vigorous suctioning through the mouth (Choice D) can lead to increased trauma and worsen bleeding. Encouraging the client to cough out the bloody secretions (Choice C) is not appropriate since the client undergoing suctioning is typically unable to expectorate secretions. Therefore, the priority is to check and adjust the suction settings to ensure safe and effective suctioning.

3. After a session of hemodialysis, the nurse should monitor the client for which of the following complications of hemodialysis?

• A. Hyperkalemia.
• B. Hypotension.
• C. Infection.
• D. Fever.

Correct answer: B

Rationale: The correct answer is 'B: Hypotension.' Hypotension is a common complication of hemodialysis because fluid removal during the process can lead to a drop in blood pressure. The nurse should closely monitor the client for signs of hypotension such as dizziness, lightheadedness, or a decrease in blood pressure readings. Choice 'A: Hyperkalemia' is incorrect because hemodialysis actually helps lower potassium levels by removing excess potassium from the blood. Choice 'C: Infection' is incorrect as it is not a direct complication of hemodialysis but rather a risk associated with invasive procedures. Choice 'D: Fever' is incorrect as fever is not a typical immediate post-hemodialysis complication unless an underlying infection is present.

4. The client with chronic renal failure asks why a low-protein diet is necessary. Which of the following is the best response by the nurse?

• A. It reduces the workload on your kidneys.
• B. It helps prevent the buildup of waste products.
• C. It helps maintain electrolyte balance in your body.
• D. It helps prevent dehydration.

Correct answer: B

Rationale: A low-protein diet is necessary for clients with chronic renal failure to help prevent the buildup of waste products, such as urea, in the body. Choice A is incorrect as the primary reason for a low-protein diet is to manage waste product accumulation rather than reducing the workload on the kidneys. Choice C is incorrect as electrolyte balance is typically managed through dietary restrictions beyond protein intake. Choice D is incorrect as preventing dehydration is not the primary purpose of a low-protein diet in chronic renal failure.

5. The nurse observes an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a transurethral resection of the prostate (TURP). What is the best initial nursing action?

• A. Provide additional oral fluid intake
• B. Measure the client's intake and output
• C. Increase the flow of the bladder irrigation
• D. Administer a PRN dose of an antispasmodic agent

Correct answer: C

Rationale: The best initial nursing action when observing an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation post-TURP is to increase the flow of the bladder irrigation. This action helps prevent blood clots from obstructing the catheter, ensuring effective drainage and promoting client comfort. Providing additional oral fluid intake (Choice A) is important for overall hydration but may not directly address the issue of blood clots in the drainage tubing. Measuring the client's intake and output (Choice B) is a routine nursing assessment that may not directly address the immediate concern of blood clots obstructing the catheter. Administering a PRN dose of an antispasmodic agent (Choice D) is not the best initial action as it does not directly address the issue of blood clots in the drainage tubing.

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