Nursing Elites

1. A client at risk for mild hypernatremia is being taught by a nurse. Which statement should the nurse include in this client's teaching?

• A. Weigh yourself every morning and every night
• B. Check your radial pulse twice a day
• C. Read food labels to determine sodium content
• D. Bake or grill the meat rather than frying it

Correct answer: C

Rationale: The correct answer is to 'Read food labels to determine sodium content.' This is important for a client at risk for mild hypernatremia because monitoring sodium intake is crucial in managing this condition. Choice A is not directly related to managing hypernatremia. Choice B focuses on pulse monitoring, which is not specific to managing sodium levels. Choice D addresses cooking methods, which can be beneficial but is not as directly related to sodium intake monitoring as reading food labels.

2. The physician has ordered a peripheral IV to be inserted before the patient goes for computed tomography. What should the nurse do when selecting a site on the hand or arm for insertion of an IV catheter?

• A. Choose a site with minimal hair if available.
• B. Consider potential effects on the patient's mobility when selecting a site.
• C. Instruct the patient to hold his arm in a dependent position before insertion.
• D. Remove the tourniquet after 2 minutes.

Correct answer: B

Rationale: When selecting a site for IV insertion on the hand or arm, it is important to consider the potential effects on the patient's mobility. The chosen site should not interfere with the patient's movement. Instructing the patient to hold his arm in a dependent position helps increase blood flow, aiding in vein visualization and insertion. It is advisable to choose a site with minimal hair if possible for better adhesion of the dressing. Removing the tourniquet after 2 minutes is recommended to prevent complications like hemoconcentration and potential vein damage. Therefore, option B is the correct choice as it aligns with best practices for IV insertion.

3. A nurse preparing to start an IV on a newly admitted patient teaches the patient about the procedure and begins to prepare the site. The nurse should always start by:

• A. Leaving one hand ungloved to assess the site
• B. Preparing the skin with an iodine solution
• C. Asking the patient if they are allergic to latex or iodine
• D. Removing excessive hair at the selected site

Correct answer: C

Rationale: Before preparing the skin, the nurse should ask the patient if they are allergic to latex or iodine, which are commonly used in IV therapy setup. This is crucial to prevent potential allergic reactions at the IV site or even life-threatening anaphylaxis. Leaving one hand ungloved (choice A) is not a recommended practice as both hands should be gloved for infection control. While preparing the skin with an iodine solution (choice B) is a step in the process, ensuring the patient's safety by checking for allergies comes first. Removing excessive hair at the selected site (choice D) is not necessary and can lead to skin irritation.

4. After administering 40 mEq of potassium chloride, a nurse evaluates the clients response. Which manifestations indicate that treatment is improving the clients hypokalemia? (Select all tha do not t apply.)

• A. Strong productive cough
• B. Active bowel sounds
• C. U waves present on the electrocardiogram (ECG)
• D.

Correct answer: C

Rationale:

5. A nurse educator is reviewing peripheral IV insertion with a group of novice nurses. How should these nurses be encouraged to deal with excess hair at the intended site?

• A. Leave the hair intact
• B. Shave the area.
• C. Clip the hair in the area.
• D. Remove the hair with a depilatory.

Correct answer: C

Rationale:

Similar Questions