Nursing Elites

1. The nurse is taking the vital signs of a client after hemodialysis. Blood pressure is 110/58 mm Hg, pulse 66 beats/min, and temperature is 99.8°F (37.6°C). What is the most appropriate action by the nurse?

• A. Administer fluids to increase blood pressure.
• B. Check the white blood cell count.
• C. Monitor the client’s temperature.
• D. Connect the client to an electrocardiographic (ECG) monitor.

Correct answer: C

Rationale: After hemodialysis, it is crucial to monitor the client's temperature because the dialysate is warmed to increase diffusion and prevent hypothermia. The client's temperature might reflect the temperature of the dialysate. There is no need to administer fluids to increase blood pressure as the vital signs are within normal limits. Checking the white blood cell count or connecting the client to an ECG monitor is not necessary based on the information provided.

2. For a client with peripheral vascular disease (PVD) of the lower extremities who is trying to manage their condition well, which routine should the nurse evaluate as appropriate?

• A. Resting with the legs elevated above the level of the heart.
• B. Walking slowly but steadily for 30 minutes twice a day.
• C. Minimizing activity.
• D. Wearing antiembolism stockings at all times when out of bed.

Correct answer: B

Rationale: The correct answer is B. Walking slowly but steadily for 30 minutes twice a day is appropriate for clients with PVD as it helps stimulate collateral circulation and improve blood flow. Choice A is incorrect because while elevating the legs can help with symptoms temporarily, it is not as effective as walking for improving circulation. Choice C, minimizing activity, is not recommended as it can lead to further deconditioning and worsen symptoms. Choice D, wearing antiembolism stockings, is not specifically indicated for PVD and may not address the underlying circulation issues.

3. The client with chronic renal failure is receiving hemodialysis. Which of the following laboratory values should the nurse monitor closely?

• A. Hemoglobin level.
• B. Blood urea nitrogen (BUN) level.
• C. Serum potassium level.
• D. Creatinine level.

Correct answer: C

Rationale: The serum potassium level should be monitored closely in clients undergoing hemodialysis due to the risk of hyperkalemia. Hemodialysis is used to remove waste products and excess electrolytes like potassium from the blood. Monitoring potassium levels is crucial because an imbalance can lead to serious cardiac complications, making it the priority value to monitor in this scenario. Monitoring hemoglobin levels (choice A) is important for anemia assessment in chronic renal failure but is not directly related to hemodialysis. Blood urea nitrogen (BUN) levels (choice B) and creatinine levels (choice D) are commonly monitored in renal function tests but are not the top priority for monitoring in a client undergoing hemodialysis.

4. 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.

5. The nurse assesses a client with advanced cirrhosis of the liver for signs of hepatic encephalopathy. Which finding would the nurse consider an indication of progressive hepatic encephalopathy?

• A. An increase in abdominal girth.
• B. Hypertension and a bounding pulse.
• C. Decreased bowel sounds.
• D. Difficulty in handwriting.

Correct answer: D

Rationale: Difficulty in handwriting is a common early sign of hepatic encephalopathy. Changes in handwriting can indicate progression or reversal of hepatic encephalopathy leading to coma. Choice (A) is a sign of ascites, not hepatic encephalopathy. Hypertension and a bounding pulse (Choice B) are not typically associated with hepatic encephalopathy. Decreased bowel sounds (Choice C) do not directly indicate an increase in serum ammonia level, which is the primary cause of hepatic encephalopathy.

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