Exit Exam (BSN 366)

Correct Answer:

Serum potassium, calcium, and phosphorus.

Why this is correct:

Clients with end-stage renal disease (ESRD) often experience significant electrolyte imbalances and mineral metabolism disorders due to impaired kidney function. The kidneys play a key role in regulating potassium, calcium, and phosphorus levels, and their dysfunction leads to dangerous complications:

Potassium (K⁺): In ESRD, the kidneys' ability to excrete potassium is impaired, leading to hyperkalemia. This can cause life-threatening cardiac arrhythmias and potentially cardiac arrest.

Calcium (Ca²⁺): Due to impaired kidney function, the activation of vitamin D is reduced, leading to hypocalcemia. This condition affects calcium absorption and promotes bone disease such as osteodystrophy (bone demineralization).

Phosphorus (P): The kidneys are responsible for excreting phosphorus, and in ESRD, hyperphosphatemia occurs. This disrupts the calcium-phosphorus balance and can contribute to vascular calcification and bone disease, making monitoring essential.

Why the other options are incorrect:

Erythrocytes, hemoglobin, and hematocrit:

While anemia is a common issue in ESRD due to decreased production of erythropoietin (a hormone that stimulates red blood cell production), electrolyte imbalances (especially potassium) are more immediately life-threatening. Potassium levels can directly affect cardiac function, posing a much more urgent risk compared to anemia.

Blood pressure, heart rate, and temperature:

Hypertension is common in ESRD due to fluid overload and dysfunction of the renin-angiotensin system. While blood pressure monitoring is important, potassium imbalances present a more immediate risk to cardiac health. Hyperkalemia, in particular, can lead to arrhythmias and other cardiac complications that are more pressing than blood pressure monitoring.

Leukocytes, neutrophils, and thyroxine:

While ESRD can impair the immune system and affect thyroid function (thyroxine), the primary concern in ESRD management is electrolyte and mineral imbalances. Monitoring for infections (through leukocytes and neutrophils) is important but not the immediate priority. Thyroxine levels are also less critical in the acute management of ESRD compared to addressing potassium, calcium, and phosphorus imbalances.

Correct Answer:

Review the need for the UAP to wear a facemask while in close contact with the client

Influenza is transmitted via respiratory droplets, which can spread through coughing, sneezing, or talking. According to CDC guidelines, droplet precautions are necessary, and healthcare workers must wear a surgical mask when within 3 to 6 feet of a client with influenza. Although the unlicensed assistive personnel (UAP) is wearing gloves and a gown, a surgical facemask is also required to prevent transmission and ensure both client and caregiver safety.

Why the other options are incorrect:

“Remind the UAP to apply a fitted respirator mask before entering the client’s room”

This applies to airborne precautions, not droplet precautions. Diseases like tuberculosis or measles require an N95 respirator, but for influenza, a standard surgical mask is sufficient.

“Assign the UAP to provide care for another client and assume full care of the client”

This is unnecessary. The UAP can continue providing care if appropriate droplet precautions—including the use of a facemask—are followed. Delegation is safe when infection control protocols are met.

“Instruct the UAP to notify the nurse of any changes in the client’s respiratory status”

Although monitoring for changes is good practice, this does not address the current problem: the UAP is missing a key component of droplet precautions. The immediate concern is proper PPE use to prevent transmission.

The correct answer is:

Maintain a semi-Fowler position.

Explanation:

The priority nursing intervention post-thyroidectomy is maintaining a semi-Fowler position. This position helps to reduce the risk of aspiration and supports optimal respiratory function by elevating the head and neck. It also minimizes pressure on the surgical incision site, promoting healing and reducing strain. Additionally, this position helps prevent complications such as respiratory distress, swelling, or airway obstruction, which are particularly crucial during the first 12 hours post-surgery, when the client is at risk for complications like bleeding or airway compromise.

Why the Other Options Are Incorrect:

Resume anti-thyroid drug therapy

Anti-thyroid drugs are typically used to treat hyperthyroidism, not immediately after a thyroidectomy. After surgery, the client is more likely to require thyroid hormone replacement therapy, especially if the entire thyroid is removed. Anti-thyroid drugs such as methimazole or propylthiouracil are not appropriate immediately post-thyroidectomy unless there is residual thyroid tissue, which is uncommon.

Prepare to administer radioactive iodine treatment

Radioactive iodine treatment is not typically given immediately after a thyroidectomy. It is generally reserved for cases such as thyroid cancer or hyperthyroidism (e.g., Graves' disease), and often used later in the treatment plan. It is not a standard intervention immediately following thyroid surgery unless specifically indicated by the surgical outcomes or diagnosis.

Anticipate and monitor for hypothermia

Although hypothermia can occur after surgery, it is not a primary concern immediately after thyroidectomy unless there are specific complications such as prolonged anesthesia or significant blood loss. Hypothermia is more common in environments with excessive cold exposure. The main focus post-thyroidectomy is preventing airway compromise and managing respiratory status, which is why positioning is the priority.

 Correct Answer: Get an eye exam with an ophthalmologist annually.

Why this is Correct:

People with diabetes need yearly dilated eye exams to catch diabetic retinopathy early​

High blood sugar can damage retinal vessels, so seeing an ophthalmologist every year helps prevent vision loss. An annual eye exam is a standard recommendation for diabetic clients and shows the patient understands long-term complication prevention

By saying they will get yearly eye exams, the client demonstrates knowledge of necessary routine care (similar to how they should also get annual foot exams, etc.).

Why Others are Wrong:

Using salt, herbs, and spices will improve food flavor: This doesn’t address diabetes management. In fact, diabetics should limit salt to help blood pressure, and flavoring food (while fine) isn’t a key teaching point for DM control. It misses critical aspects like carbohydrate monitoring or foot care, so it doesn’t indicate true understanding.

Arrange diet around three regular meals a day: Diabetes meal planning is more nuanced. Simply eating three set meals may not be ideal for blood sugar control. Some patients do better with smaller, frequent meals or carb counting. This answer doesn’t reflect specific diabetic diet education (like balancing carbs) – it’s too generic.

Inspect feet every month: Diabetics must inspect their feet daily, not monthly! Daily foot checks catch cuts or sores early (since neuropathy may prevent feeling injuries). A monthly check is far too infrequent and would concern the nurse that the client didn’t grasp foot care teaching.

Summary 

Diabetic clients should have yearly eye exams to screen for retinopathy​. They also need daily foot inspections (not monthly) to catch sores early. Good diabetes management includes regular screenings and daily self-care routines. The American Diabetes Association recommends annual ophthalmologic exams for diabetics to prevent complications like blindness​. It also stresses daily foot care and frequent monitoring of diet and blood sugar – making option B the only statement showing correct understanding.

Selected Priorities:

A, B, D, E, G, J

A) Feed immediately. Early feeding (breast or formula) is the first-line treatment for neonatal hypoglycemia. At BG 35, the infant needs glucose now – feeding can often raise blood sugar into safe range. It’s noninvasive and critical to do right away.

B) Monitor for respiratory distress. IDMs are at risk for Respiratory Distress Syndrome, plus this baby’s RR was 80 (tachypnea). Continuous observation for grunting, flaring, retractions is vital so interventions (oxygen, CPAP) can be started promptly if needed. Monitoring breathing is a high priority in any newborn showing possible distress.

D) Keep in warmer with bili lights. The infant’s temp is 96°F (hypothermic) – placing the baby under a radiant warmer stabilizes temperature. The mention of “bili lights” suggests using a warmer that also has phototherapy, anticipating possible jaundice (bilirubin was 7 mg/dL, slightly high). Warmth is critical to prevent cold stress, which can worsen hypoglycemia. So yes, keep baby in a warmer (and phototherapy can run as needed).

E) Monitor temperature every 30 min. Given the baby’s low temp, frequent checks are needed to ensure re-warming efforts are effective. Temp q30min until stable is appropriate to avoid under- or overheating. This frequent monitoring is a priority to track improvement.

G) Contact RT for ABG and O₂ therapy. In a jittery, tachypneic IDM, there’s concern for respiratory issues. Getting Respiratory Therapy involved for an arterial blood gas and possible oxygen support ensures we address any RDS quickly. An ABG can assess oxygenation and acid-base status. If RR is 80 and maybe grunting, starting some O₂ or getting RT to evaluate is prudent. Early RT involvement is better than late if distress is present.

J) Check blood glucose level (re-check) after interventions. We fed the baby; now we must follow up BG to see if it improved. Monitoring glucose is an ongoing priority until stable. A repeat BG (likely 30 min to 1 hr after feeding) tells us if additional interventions (like dextrose gel or IV glucose) are needed. So continuing to measure BG is crucial.

These six actions address the baby’s acute issues: hypoglycemia (feed, re-check BG), hypothermia (warmer, temp monitoring), and risk of RDS (monitor breathing, involve RT). They align with the case’s expected priorities for an IDM who is symptomatic.

Why other orders are lower priority:

C) Apply dextrose gel in cheek: Buccal dextrose gel is second-line if feeding fails to correct BG. We would try feeding first (as we did in A). If BG remains low, then gel can be used. It’s important, but after seeing if feeding works. So it’s slightly lower priority than initial feed and re-check.

F) IV bolus of D10W 2 mL/kg: IV dextrose is indicated for severe or refractory hypoglycemia. At BG 35 with some symptoms (jittery), we attempt feed (and gel) first. If those fail, or if baby was very symptomatic or BG <20–25, then IV would be urgent. In this case, baby is jittery but not seizing or unconscious, so we can try lesser invasive measures first. Thus, the IV bolus is held in reserve if BG doesn’t improve.

H) Echocardiogram: While IDMs can have cardiomyopathy, an immediate echo is not typically an emergency unless signs of cardiac distress exist. It’s not a priority in the first hour of life compared to warmth, glucose, breathing. It might be done later if baby has a murmur or poor perfusion. But not a “priority” order right now.

I) Transfer to NICU: You’d transfer if the baby remains unstable or needs aggressive intervention (like ventilator or ongoing IV glucose). Initially, we try to stabilize in the newborn nursery. If we can’t, then NICU transfer happens. It’s not automatic unless these measures fail. So I is not first-line unless baby decompensates despite our interventions.

Summary:

Neonatal hypoglycemia management calls for immediate feeding and glucose monitoring. Thermoregulation (use of warmers) is crucial at 96°F to prevent further metabolic stress. RDS risk in IDMs necessitates vigilant respiratory monitoring and readiness for oxygen/ventilation support. The prioritized orders (A, B, D, E, G, J) cover these bases. Buccal gel and IV glucose are contingency steps if feeding doesn’t suffice. NICU transfer and echo are higher-level interventions if initial stabilization isn’t achieved.

Correct Answer: Persistent coughing while drinking

Persistent coughing while drinking is a classic sign of dysphagia, which is common after a stroke. Dysphagia occurs when there is difficulty swallowing, and it can lead to aspiration, where food or liquid enters the airway instead of the esophagus. This increases the risk of aspiration pneumonia, a serious complication. Speech therapists specialize in evaluating and treating dysphagia. They can assess the patient's swallowing function and teach strategies to reduce the risk of aspiration, making this the most appropriate reason to refer the client for speech therapy.

Why the other options are incorrect:

Inappropriate or exaggerated mood swings

While mood swings are common after a stroke due to changes in brain function or emotional regulation, they do not directly relate to swallowing or speech. These symptoms would be better addressed by a mental health professional or neurologist rather than a speech therapist, who specializes in communication and swallowing disorders.

Abdominal responses for cranial nerves I and II

Cranial nerves I (olfactory) and II (optic) are related to the senses of smell and vision, respectively. The abdominal responses are not relevant to these cranial nerves. Assessing cranial nerve function is important for neurological evaluation but not specifically for speech therapy, as these nerves do not impact swallowing or speech directly.

Unilateral facial drooping

Unilateral facial drooping is a common sign of a stroke affecting the facial nerve (cranial nerve VII), leading to facial weakness. Although speech therapists may assist with facial exercises if facial drooping affects speech production, this issue is primarily related to facial motor control. It is not directly related to swallowing and speech difficulties, making a referral for speech therapy less urgent in this case.

Correct Answer: Hand washing prior to preparation of the injection.

Rationale:

Hand washing is the most important action to ensure sterility when preparing and administering a subcutaneous injection. Proper hand hygiene prevents the transfer of microorganisms from the nurse's hands to the needle, syringe, medication, and the injection site, all of which could lead to infection. Hand washing is a fundamental practice in maintaining sterile technique and preventing contamination.

Explanation of Other Options:

Method used to aspirate medication from a vial:

While it is important to follow the proper technique when drawing medication from a vial, aspiration (pulling back the plunger to check for blood) is generally not required for subcutaneous injections, unless specifically directed by protocol (such as for certain intramuscular injections). Aspiration does not play a central role in ensuring sterility for subcutaneous injections.

Selection and rotation of injection sites:

Rotating injection sites is important to prevent tissue damage and complications like lipodystrophy from frequent injections in the same area. However, this step is more concerned with tissue health and not the sterility of the injection process itself.

Proper disposal of injection equipment:

While it is critical to dispose of needles and syringes properly after the injection to avoid injury and contamination, this action occurs after the injection and does not affect the sterility of the injection process.

The correct answers are:

Report serum albumin and globulin levels.

Note signs of swelling and edema.

Monitor abdominal girth.

Explanation:

Reporting serum albumin and globulin levels: In cirrhosis, the liver's ability to produce proteins like albumin is impaired. Low albumin levels are common and contribute to fluid retention and edema. Elevated globulin levels may indicate an immune or inflammatory response related to liver disease. Monitoring these levels is essential for evaluating liver function and guiding appropriate treatment.

Noting signs of swelling and edema: Swelling and edema are signs of fluid retention, a common issue in cirrhosis due to portal hypertension and decreased albumin production. Monitoring for peripheral edema and ascites is crucial, as these complications require interventions such as diuretics or paracentesis.

Monitoring abdominal girth: Abdominal girth measurement is key for tracking ascites in cirrhosis. As fluid accumulates in the abdomen, measuring girth helps assess treatment effectiveness (e.g., diuretics or paracentesis) and informs fluid management decisions.

Why the other options are incorrect:

Providing a diet low in phosphorus is not a priority in cirrhosis. Instead, dietary focus should be on sodium restriction, calorie provision, and protein intake based on disease stage. Phosphorus control is more relevant to kidney disease.

Increasing oral fluid intake to 1500 mL daily is typically not recommended in cirrhosis with complications like ascites or edema. Fluid intake is usually restricted to prevent worsening fluid retention.

The Correct Answer:

Check for a distended bladder.

Explanation:

A firm uterus that is positioned three fingerbreadths above the umbilicus on the first postpartum day is abnormal and suggests bladder distention. Normally, the uterus should be at or below the umbilicus as it involutes (shrinks) following delivery. A distended bladder can push the uterus upward and to the side, preventing proper contraction and increasing the risk of postpartum hemorrhage. The nurse’s first priority should be assessing the bladder and encouraging the patient to void if it is distended.

Why the Other Options Are Incorrect:

Increase IV infusion:

While increasing IV fluids might be necessary in cases of postpartum hemorrhage or hypovolemia, there is no indication that the patient is actively hemorrhaging. The presence of a moderate amount of lochia rubra and a firm uterus suggests that the bleeding is not excessive at this time. The priority is to assess the underlying cause of the elevated uterine position.

Massage the uterus to decrease atony:

Uterine atony (lack of muscle tone leading to excessive bleeding) would be suspected if the uterus were boggy (soft and non-firm). In this case, the uterus is firm, which means it is contracting appropriately. Massaging a firm uterus is unnecessary and could cause excessive stimulation, potentially leading to increased bleeding.

Review the hemoglobin to determine hemorrhage:

While monitoring hemoglobin levels is important for assessing blood loss, it is not the first priority in this situation. The key issue here is the abnormally high uterine position, which suggests bladder distention. Addressing this will help prevent further complications, including increased bleeding.