Nursing Elites

1. The nurse is monitoring a client who is receiving continuous ambulatory peritoneal dialysis. The nurse should notify the physician of which of the following findings?

• A. Clear dialysate outflow.
• B. Cloudy dialysate outflow.
• C. Decreased urine output.
• D. Increased blood pressure.

Correct answer: B

Rationale: Cloudy dialysate outflow is an indication of peritonitis, a serious complication of peritoneal dialysis that requires immediate medical attention. Clear dialysate outflow is a normal finding indicating proper dialysis function and should not raise concern. Decreased urine output may be expected in a client undergoing dialysis due to the removal of excess fluids from the body. Increased blood pressure is a common complication in clients with kidney disease but is not directly related to cloudy dialysate outflow.

2. A client recovering from extracorporeal shock wave lithotripsy for renal calculi has an ecchymotic area on the right lower back. What action should the nurse take?

• A. Administer fresh-frozen plasma.
• B. Apply an ice pack to the site.
• C. Place the client in the prone position.
• D. Obtain serum coagulation test results.

Correct answer: B

Rationale: After extracorporeal shock wave lithotripsy, ecchymosis can occur due to bleeding into the tissues from the shock waves. Applying an ice pack helps reduce the extent and discomfort of bruising. Administering fresh-frozen plasma and obtaining coagulation test results are not necessary as ecchymosis after this procedure is common and does not indicate a bleeding disorder that requires immediate intervention. Placing the client in the prone position will not address the bleeding or bruising in this situation.

3. A client with polycystic kidney disease (PKD) is being discharged. Which statements should the nurse include in this client’s discharge teaching? (Select all that apply.)

• A. Take your blood pressure every morning.
• B. Weigh yourself at the same time each day.
• C. Contact your provider if you have visual disturbances.
• D. All of the above

Correct answer: D

Rationale: A client with polycystic kidney disease (PKD) should be educated on monitoring their blood pressure daily and weighing themselves consistently to detect any changes promptly. It is essential to contact the healthcare provider if visual disturbances occur, as this could indicate a complication such as a berry aneurysm associated with PKD. Foul-smelling or bloody urine should also prompt notification to the provider as they could signify urinary tract infections or glomerular injury. Choices A, B, and C are correct as they address crucial aspects of managing PKD and its potential complications. Choices A and B help in monitoring for changes in blood pressure and fluid status, while choice C focuses on detecting possible neurological complications. Choices A, B, and C are relevant to PKD management and should be included in the client's discharge teaching. Choices that mention diarrhea and renal stones are not directly associated with PKD; therefore, teaching related to these conditions would be irrelevant in this context.

4. A client in the postanesthesia care unit has an as-needed prescription for ondansetron (Zofran). Which of the following occurrences would prompt the nurse to administer this medication to the client?

• A. Paralytic ileus
• B. Incisional pain
• C. Urine retention
• D. Nausea and vomiting

Correct answer: D

Rationale: The correct answer is D: Nausea and vomiting. Ondansetron is an antiemetic used to manage postoperative nausea and vomiting, as well as nausea and vomiting related to chemotherapy. It is not indicated for treating paralytic ileus, incisional pain, or urine retention. Paralytic ileus is a condition of the gastrointestinal tract characterized by the paralysis of intestinal muscles, which would not be treated with ondansetron. Incisional pain is typically managed with analgesics, not antiemetics. Urine retention is a urinary issue that does not involve nausea and vomiting, making ondansetron an inappropriate choice for this condition.

5. A client who is anxious about an impending surgery is at risk for respiratory alkalosis. For which signs and symptoms of respiratory alkalosis does the nurse assess this client?

• A. Disorientation and dyspnea
• B. Drowsiness, headache, and tachypnea
• C. Tachypnea, dizziness, and paresthesias
• D. Dysrhythmias and decreased respiratory rate and depth

Correct answer: C

Rationale: The correct answer is C: Tachypnea, dizziness, and paresthesias. When a client is anxious, they may hyperventilate, leading to respiratory alkalosis. Tachypnea (rapid breathing) is a common sign of respiratory alkalosis. Dizziness and paresthesias (tingling or numbness in the extremities) are also typical symptoms. Choices A, B, and D are incorrect. Disorientation and dyspnea (Choice A) are not specific signs of respiratory alkalosis. Drowsiness, headache, and tachypnea (Choice B) may be more indicative of other conditions. Dysrhythmias and decreased respiratory rate and depth (Choice D) are not consistent with the expected signs of respiratory alkalosis.

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