Nursing Elites

1. 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.

2. When conducting discharge teaching for a client diagnosed with diverticulitis, which diet instruction should the nurse include?

• A. Have small, frequent meals and sit up for at least two hours after meals
• B. Eat a bland diet and avoid spicy foods
• C. Eat a high-fiber diet and increase fluid intake
• D. Eat a soft diet with increased intake of milk and milk products

Correct answer: C

Rationale: For a client diagnosed with diverticulitis, the nurse should instruct them to eat a high-fiber diet and increase fluid intake. This diet helps in managing diverticulitis by promoting bowel regularity and preventing complications such as diverticular inflammation or infection. Choice A of having small, frequent meals and sitting up for at least two hours after meals may be beneficial for gastroesophageal reflux disease but is not specific to diverticulitis. Choice B of eating a bland diet and avoiding spicy foods is not the preferred recommendation for diverticulitis management. Choice D of eating a soft diet with increased intake of milk and milk products may not provide enough fiber to aid in diverticulitis management, and the increased intake of dairy products may worsen symptoms in some individuals.

3. A client with stress incontinence is being taught about pelvic muscle exercises. Which statements should be included by the nurse? (Select all that apply.)

• A. Starting and stopping the urine stream involves using pelvic muscles.
• B. Tighten pelvic muscles for a slow count of 10 and then relax for a slow count of 10.
• C. Pelvic muscle exercises can be performed in various positions: lying down, sitting up, and standing.
• D. A & B

Correct answer: D

Rationale: The correct statements to include when teaching a client with stress incontinence about pelvic muscle exercises are that starting and stopping the urine stream involve using pelvic muscles and that tightening pelvic muscles for a slow count of 10 and then relaxing for a slow count of 10 can help strengthen them. It is essential to highlight that pelvic muscle exercises can be performed in various positions, including lying down, sitting up, and standing. This variety in positions helps engage the muscles effectively. Performing these exercises 15 times in each position can aid in strengthening the pelvic floor muscles. Consistent exercise over several weeks typically leads to improved control over urine leakage. Choice C is incorrect because pelvic muscle exercises can be performed in different positions and are not limited to sitting upright with feet on the floor.

4. In a patient with anemia, which of the following is the primary symptom to assess?

• A. Fever.
• B. Chest pain.
• C. Shortness of breath.
• D. Muscle cramps.

Correct answer: C

Rationale: The correct answer is C: Shortness of breath. In a patient with anemia, the primary symptom to assess is shortness of breath. Anemia leads to a reduced oxygen-carrying capacity of the blood, resulting in tissues not receiving adequate oxygen. This can manifest as shortness of breath, especially during physical exertion. Fever (Choice A), chest pain (Choice B), and muscle cramps (Choice D) are not typically primary symptoms of anemia. Fever may suggest an infection, chest pain can be indicative of cardiac issues, and muscle cramps may be related to electrolyte imbalances or neuromuscular disorders.

5. 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.

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