Nursing Elites

1. A client at risk for developing hyperkalemia states, 'I love fruit and usually eat it every day, but now I can't because of my high potassium level.' How should the nurse respond?

• A. Potatoes and avocados can be substituted for fruit.
• B. If you cook the fruit, the amount of potassium will be lower.
• C. Berries, cherries, apples, and peaches are low in potassium.
• D. You are correct. Fruit is very high in potassium.

Correct answer: C

Rationale: The correct answer is C. Berries, cherries, apples, and peaches are indeed low in potassium, making them suitable choices for someone at risk for hyperkalemia. Choice A is incorrect because potatoes and avocados are high in potassium and should be avoided in this situation. Choice B is incorrect because cooking fruit does not significantly lower its potassium content. Choice D is incorrect as it provides incorrect information, as not all fruits are very high in potassium.

2. 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.

3. Which of the following organs does not contribute to fluid output from the body?

• A. Lungs
• B. Skin
• C. Intestine
• D. Lungs, skin, and intestine

Correct answer: D

Rationale: The correct answer is D. All the listed organs (lungs, skin, and intestines) contribute to fluid loss from the body. Lungs contribute to fluid loss through respiration, skin through sweating, and intestines through excretion. Therefore, none of the organs listed in the options retain fluids within the body. Choices A, B, and C are incorrect because all of these organs play a role in fluid output from the body.

4. A nurse is caring for a client who is experiencing excessive diarrhea. The clients arterial blood gas values are pH 7.28, PaO2 98 mm Hg, PaCO2 45 mm Hg, and HCO3 16 mEq/L. Which provider order should the nurse expect to receive?

• A. Furosemide (Lasix) 40 mg intravenous push
• B. Sodium bicarbonate 100 mEq diluted in 1 L of D5W
• C. Mechanical ventilation
• D. Indwelling urinary catheter

Correct answer: B

Rationale:

5. While assessing a clients peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 4-cm venous cord. How should the nurse document this finding?

• A. Grade 3 phlebitis at IV site
• B. infection at IV site
• C. Thrombosed area at IV site
• D. infiltration at IV site

Correct answer: A

Rationale:

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