Nursing Elites

1. How can a nurse recognize that a chronic renal failure client's AV shunt is patent?

• A. Absence of a bruit
• B. Presence of a thrill
• C. Blood return from the shunt
• D. Urine output greater than 30 ml/hr

Correct answer: B

Rationale: The correct assessment to determine the patency of an AV shunt in a chronic renal failure client is the presence of a thrill. A thrill is a vibration or buzzing sensation felt over the shunt site, indicating good blood flow through the shunt. While the presence of a bruit is also important for assessing an AV shunt, a thrill is a more specific indicator of patency. Blood return from the shunt is related to cannulation and not necessarily an indicator of patency. Urine output greater than 30 ml/hr is not directly related to the assessment of an AV shunt's patency.

2. What is the priority nursing action for a laboring client dilated to 6 cm receiving an epidural?

• A. Continuous monitoring of maternal blood pressure.
• B. Frequent auscultation of the fetal heart rate.
• C. Administering an IV fluid bolus of at least 500 cc.
• D. Frequent monitoring of the maternal temperature.

Correct answer: A

Rationale: The priority nursing action for a laboring client dilated to 6 cm receiving an epidural is continuous monitoring of maternal blood pressure. This is crucial because epidural anesthesia can lead to a precipitous drop in blood pressure, which can be dangerous for both the mother and fetus by reducing cardiac output and placental perfusion. While frequent auscultation of the fetal heart rate is important, it is not the priority in this situation. Administering an IV fluid bolus of at least 500 cc may not be necessary if the client's blood pressure is stable. Monitoring the maternal temperature is also essential but takes precedence over blood pressure monitoring.

3. A 3-day post-operative client with a Left Knee Replacement is complaining of being chilled and nauseated. Her TPR is 100.4-94-28 and Blood Pressure is 146/90. What is the nurse's best action?

• A. Call the surgeon immediately.
• B. Administer Extra Strength Tylenol per orders.
• C. Assess the surgical site.
• D. Offer extra blankets and increase fluids.

Correct answer: A

Rationale:

4. When teaching about preventable diseases, the importance of getting the following vaccines should be emphasized:

• A. human papillomavirus, genital herpes, measles.
• B. pneumonia, HIV, mumps.
• C. syphilis, gonorrhea, pneumonia.
• D. polio, pertussis, measles

Correct answer: D

Rationale: Vaccines are crucial in preventing communicable diseases. Smallpox has been eradicated globally, so its vaccine is no longer used. Polio, pertussis, and measles are diseases that are controlled by routine childhood immunization. While smallpox has been eradicated, these diseases still exist, making it essential for children to be vaccinated against them. Choices A, B, and C include diseases that are not prevented by vaccination or are not related to routine immunizations, making them incorrect choices.

5. The LPN is preparing to ambulate a client post total knee replacement. Which of the following actions should the nurse perform prior to ambulating the client?

• A. Assist the client to a sitting position at the edge of the bed
• B. Have the client march in place for 30 seconds
• C. Have the client raise his arms above his head
• D. Ask the client the last time he fell

Correct answer: A

Rationale: The correct action to perform before ambulating a client post total knee replacement is to assist the client to a sitting position at the edge of the bed. This step is crucial to prevent orthostatic hypotension and ensure the client is ready to stand and walk safely. Having the client march in place or raise his arms above his head are not necessary preparations for ambulation. While knowing about the client's fall history is important for safety reasons, it is not the priority action immediately before ambulating the client.

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