Nursing Elites

1. The healthcare provider is assessing a client with chronic renal failure who is receiving hemodialysis. Which of the following findings would indicate that the client is experiencing a complication of the treatment?

• A. Clear dialysate outflow.
• B. Blood pressure of 150/90 mm Hg.
• C. Increased heart rate.
• D. Fatigue.

Correct answer: B

Rationale: A blood pressure of 150/90 mm Hg during hemodialysis may indicate fluid overload or an ineffective dialysis session, which can lead to complications such as heart failure or pulmonary edema. This finding should be reported promptly for further evaluation and intervention. Clear dialysate outflow is a normal and expected finding during hemodialysis, indicating proper filtration of waste products. Increased heart rate can be a normal compensatory response to hemodialysis due to fluid shifts and should be monitored but does not necessarily indicate a complication. Fatigue is a common symptom in clients with chronic renal failure undergoing hemodialysis and is not specific to complications of the treatment.

2. The nurse is preparing to administer doses of hydrochlorothiazide (HydroDIURIL) and digoxin (Lanoxin) to a patient who has heart failure. The patient reports having blurred vision. The nurse notes a heart rate of 60 beats per minute and a blood pressure of 140/78 mm Hg. Which action will the nurse take?

• A. Administer the medications and request an order for serum electrolytes.
• B. Give both medications and evaluate serum blood glucose frequently.
• C. Hold the digoxin and notify the provider.
• D. Hold the hydrochlorothiazide and notify the provider.

Correct answer: C

Rationale: In this scenario, the patient is experiencing symptoms of digoxin toxicity, such as blurred vision and bradycardia. When thiazide diuretics like hydrochlorothiazide are taken with digoxin, the patient is at risk of digoxin toxicity due to the potential for thiazides to cause hypokalemia. Therefore, the correct action for the nurse to take is to hold the digoxin and notify the provider. Administering the medications without addressing the potential toxicity could worsen the patient's condition. Requesting serum electrolytes (Choice A) may be necessary but holding the digoxin takes priority. Evaluating serum blood glucose (Choice B) is not relevant to the current situation. Holding hydrochlorothiazide (Choice D) is not the best option as the primary concern is the digoxin toxicity that needs to be addressed promptly.

3. Blood for arterial blood gas determinations is drawn from a client with pneumonia, and testing reveals a pH of 7.45, PCO2 of 30 mm Hg, and HCO3 of 19 mEq/L. The nurse interprets these results as indicative of:

• A. Compensated metabolic acidosis
• B. Compensated respiratory alkalosis
• C. Uncompensated metabolic alkalosis
• D. Uncompensated respiratory acidosis

Correct answer: B

Rationale: The correct answer is 'Compensated respiratory alkalosis.' In this case, the client's pH is within the normal range (7.35-7.45), indicating compensation. The low PCO2 (30 mm Hg) suggests respiratory alkalosis, while the low HCO3 (19 mEq/L) is also consistent with a compensatory response. Therefore, the client has a primary respiratory alkalosis that is being compensated for by metabolic acidosis. Choices A, C, and D are incorrect because they do not fit the pattern of the given blood gas values, which indicate respiratory alkalosis with metabolic compensation.

4. Which of the following is a common cause of acute kidney injury?

• A. Hypertension
• B. Dehydration
• C. Infection
• D. Hypotension

Correct answer: C

Rationale: Infection is a common cause of acute kidney injury because when the body fights an infection, it activates the immune response, leading to inflammation. This inflammatory response can affect the kidneys and impair their function. While hypertension (choice A) is a risk factor for chronic kidney disease, it is not a direct cause of acute kidney injury. Dehydration (choice B) can lead to prerenal acute kidney injury due to decreased blood flow to the kidneys, but infection is a more common cause of acute kidney injury. Hypotension (choice D) can contribute to prerenal acute kidney injury, but it is not a direct cause like infection.

5. Polyethylene glycol–electrolyte solution (GoLYTELY) is prescribed for a hospitalized client scheduled for a colonoscopy. The client begins to experience diarrhea after drinking the solution. Which action by the nurse is appropriate?

• A. Calling the physician
• B. Administering a cleansing enema
• C. Documenting the diarrhea in the medical record
• D. Giving intravenous replacement fluids in large amounts

Correct answer: C

Rationale: The correct action by the nurse in this situation is to document the diarrhea in the medical record. Polyethylene glycol–electrolyte solution (GoLYTELY) is a bowel evacuant used to cleanse the bowel before a colonoscopy. It is expected to cause mild diarrhea, which is a normal response to the medication. The diarrhea helps clear the bowel in preparation for the procedure. Calling the physician is not necessary unless there are complications. Administering a cleansing enema or giving intravenous replacement fluids in large amounts are not appropriate actions as they are not indicated for managing the expected diarrhea caused by GoLYTELY.

Similar Questions