Nursing Elites

1. Which of the following is most important for assessing when evaluating the effects of peritoneal dialysis?

• A. Serum potassium levels
• B. Blood pressure
• C. Daily weight
• D. Serum sodium levels

Correct answer: C

Rationale: Daily weight is the most crucial parameter to assess when evaluating the effects of peritoneal dialysis because it directly reflects fluid balance. Peritoneal dialysis involves the removal of excess fluid and waste products from the body. Monitoring daily weight enables the healthcare provider to track changes in fluid status, ensuring that the dialysis treatment is effective. While serum potassium levels, blood pressure, and serum sodium levels are important parameters to monitor in patients undergoing dialysis, they are not as directly indicative of the immediate effects of peritoneal dialysis on fluid balance as daily weight.

2. The adult client admitted to the post-anesthesia care unit (PACU) following abdominal surgery has a tympanic temperature of 94.6°F (34.8°C), a pulse rate of 88 beats/minute, a respiratory rate of 14 breaths/minute, and a blood pressure of 94/64 mmHg. Which action should the nurse implement?

• A. Take the client's temperature using another method.
• B. Raise the head of the bed to 60 to 90 degrees.
• C. Ask the client to cough and deep breathe.
• D. Check the blood pressure every five minutes for one hour.

Correct answer: A

Rationale: Taking the client's temperature using another method is the most appropriate action in this situation. A tympanic temperature of 94.6°F (34.8°C) is abnormally low and may not reflect the true core body temperature accurately. By using an alternative method, such as oral or rectal temperature measurement, the nurse can obtain a more reliable temperature reading. Raising the head of the bed (Choice B) is not directly related to addressing the low temperature. Asking the client to cough and deep breathe (Choice C) may be beneficial for respiratory function but does not address the temperature concern. Checking the blood pressure every five minutes for one hour (Choice D) is not the priority when the initial focus should be on accurate temperature assessment.

3. The patient will begin taking penicillin G procaine (Wycillin). The nurse notes that the solution is milky in color. What action will the nurse take?

• A. Call the pharmacist and report the milky color.
• B. Add normal saline to dilute the medication.
• C. Call the physician and report the milky appearance.
• D. Administer the medication as ordered by the physician.

Correct answer: D

Rationale: The correct answer is to administer the medication as ordered by the physician. Penicillin G procaine (Wycillin) is known to have a milky appearance, which is normal. The milky color should not raise concerns for the nurse as it is an expected characteristic of this medication. Calling the pharmacist (choice A) or the physician (choice C) unnecessarily would delay the administration of the medication. Adding normal saline to dilute the medication (choice B) is not appropriate and could alter the medication's effectiveness. Therefore, the nurse should proceed with administering the medication as prescribed without any further action based on its milky appearance.

4. A client with acute kidney injury has a blood pressure of 76/55 mm Hg. The health care provider ordered 1000 mL of normal saline to be infused over 1 hour to maintain perfusion. The client is starting to develop shortness of breath. What is the nurse’s priority action?

• A. Calculate the mean arterial pressure (MAP).
• B. Ask for insertion of a pulmonary artery catheter.
• C. Take the client’s pulse.
• D. Slow down the normal saline infusion.

Correct answer: D

Rationale: The nurse should recognize that the client may be developing fluid overload and respiratory distress due to the rapid normal saline infusion. The priority action is to slow down the infusion to prevent worsening respiratory distress and potential fluid overload. While calculating the mean arterial pressure (MAP) is important to assess perfusion, addressing the immediate respiratory distress takes precedence. Inserting a pulmonary artery catheter would provide detailed hemodynamic information but is not the initial step in managing acute respiratory distress. Monitoring vital signs, including the client's pulse, is crucial after adjusting the intravenous infusion to ensure a safe response to the intervention.

5. A client who has undergone abdominal surgery calls the nurse and reports that she just felt 'something give way' in the abdominal incision. The nurse checks the incision and notes the presence of wound dehiscence. The nurse immediately:

• A. Contacts the physician
• B. Documents the findings
• C. Places the client in a supine position with the legs flat
• D. Covers the abdominal wound with a sterile dressing moistened with sterile saline solution

Correct answer: D

Rationale: In the scenario described, the presence of wound dehiscence indicates a separation of the layers of the surgical incision. The immediate priority for the nurse is to cover the abdominal wound with a sterile dressing moistened with sterile saline solution. This helps to protect the wound from contamination and promotes a moist environment conducive to healing. Contacting the physician (Choice A) is important, but the initial action should be to address the wound. Documenting the findings (Choice B) is necessary but not the immediate priority. Placing the client in a supine position with the legs flat (Choice C) is not indicated in this situation as wound dehiscence requires wound care intervention.

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