Nursing Elites

1. The charge nurse of the medical-surgical unit is making staff assignments. Which staff member should be assigned to a client with chronic kidney disease who is exhibiting a low-grade fever and a pericardial friction rub?

• A. Registered nurse who just floated from the surgical unit
• B. Registered nurse who just floated from the dialysis unit
• C. Registered nurse who was assigned the same client yesterday
• D. Licensed practical nurse with 5 years of experience on this floor

Correct answer: C

Rationale: The client is exhibiting symptoms of pericarditis, which can occur with chronic kidney disease. Continuity of care is crucial to assess subtle changes in clients' conditions. Therefore, the registered nurse (RN) who previously cared for this client should be assigned again. Float nurses may lack knowledge of the unit and its clients, potentially leading to oversight of critical details. The licensed practical nurse, while experienced, may not possess the advanced assessment skills and education level of an RN to effectively evaluate and manage pericarditis in this client.

2. An older female client has normal saline infusing at 45 mL/hour. She complains of pain at the insertion site of the IV catheter. There is no redness or edema around the IV site. Which action should the nurse take?

• A. Determine which IV medications have recently been administered.
• B. Explain that without redness or edema, there is no need to re-start the IV.
• C. Consult with the healthcare provider about the best location to start a new IV.
• D. Convert the IV to a saline lock and continue to monitor the site.

Correct answer: D

Rationale: Converting the IV to a saline lock and continuing to monitor the site is the correct action in this scenario. When a client complains of pain at the IV insertion site without redness or edema, it may indicate phlebitis or irritation. Replacing the IV may not be necessary if there are no signs of infection or infiltration. Determining the IV medications administered or consulting with the healthcare provider to start a new IV are not immediate actions required for pain management at the insertion site. Therefore, the most appropriate intervention is to convert the IV to a saline lock and closely observe for any changes or complications.

3. A client is tested for HIV with the use of an enzyme-linked immunosorbent assay (ELISA), and the test result is positive. The nurse should tell the client that:

• A. HIV infection has been confirmed
• B. The client probably has an opportunistic infection
• C. The test will need to be confirmed with the use of a Western blot
• D. A positive test is a normal result and does not mean that the client is infected with HIV

Correct answer: C

Rationale: When an ELISA test for HIV is positive, it is essential to confirm the result with a Western blot. The Western blot is the confirmatory test for HIV. Choice A is incorrect because a positive ELISA test does not confirm HIV infection. Choice B is incorrect as it assumes a different diagnosis. Choice D is incorrect because a positive ELISA test does indicate potential HIV infection and requires confirmation.

4. The healthcare provider is unable to palpate the client's left pedal pulses. Which of the following actions should the healthcare provider take next?

• A. Auscultate the pulses with a stethoscope.
• B. Call the physician.
• C. Use a Doppler ultrasound device.
• D. Inspect the lower left extremity.

Correct answer: C

Rationale: When pedal pulses are not palpable, using a Doppler ultrasound device is the appropriate next step to locate the pulse. Auscultating the pulses with a stethoscope (Choice A) is used for assessing blood flow in arteries above the clavicle, not for pedal pulses. Calling the physician (Choice B) may be necessary at a later stage, but initially, using a Doppler ultrasound device to locate the pulse is more appropriate. Inspecting the lower left extremity (Choice D) can provide visual information but will not help in locating the pedal pulses, making it a less suitable option.

5. The nurse is monitoring a client with chronic renal failure who is receiving hemodialysis. The nurse should report which of the following findings immediately?

• A. Clear dialysate outflow.
• B. Weight gain of 2 lbs (0.9 kg) since the last treatment.
• C. Blood pressure of 130/80 mm Hg.
• D. Pulse rate of 72 bpm.

Correct answer: B

Rationale: The correct answer is B. Weight gain of 2 lbs (0.9 kg) since the last treatment is concerning in a client undergoing hemodialysis with chronic renal failure as it may indicate fluid overload. This finding requires immediate reporting and intervention to prevent complications such as fluid retention, pulmonary edema, or exacerbation of heart failure. Choices A, C, and D are not findings that require immediate attention in this context. Clear dialysate outflow is a normal finding during hemodialysis, a blood pressure of 130/80 mm Hg is within a normal range for many clients, and a pulse rate of 72 bpm is also within the expected range for most individuals.

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