Nursing Elites

1. A client with acute renal failure (ARF) is admitted for uncontrolled type 1 diabetes mellitus and hyperkalemia. The nurse administers an IV dose of regular insulin per sliding scale. Which intervention is the most important for the nurse to include in this client’s plan of care?

• A. Monitor the client’s cardiac activity via telemetry.
• B. Maintain venous access with an infusion of normal saline.
• C. Assess glucose levels via finger stick every 4 to 6 hours.
• D. Evaluate hourly urine output for the return of normal renal function.

Correct answer: A

Rationale: Monitoring cardiac activity is crucial in this scenario because hyperkalemia can lead to serious cardiac dysrhythmias, which can be life-threatening. Regular monitoring of the client’s cardiac activity via telemetry allows for early detection of any potential cardiac complications. Maintaining venous access with a normal saline infusion is important for hydration but does not address the immediate risk of cardiac dysrhythmias posed by hyperkalemia. Assessing glucose levels is essential in diabetes management but is not the priority when dealing with hyperkalemia-induced cardiac risks. Evaluating hourly urine output for the return of normal renal function is important in ARF but is not as urgent as monitoring the client's cardiac activity in the context of hyperkalemia.

2. What intervention should the nurse implement during the administration of a vesicant chemotherapeutic agent via an IV site in the client's arm?

• A. Assess IV site frequently for signs of extravasation
• B. Monitor capillary refill distal to the infusion site
• C. Apply a topical anesthetic at the infusion site for burning
• D. Explain that temporary burning at the IV site may occur

Correct answer: A

Rationale: The correct intervention the nurse should implement during the administration of a vesicant chemotherapeutic agent via an IV site in the client's arm is to assess the IV site frequently for signs of extravasation. Vesicants are agents that can cause tissue damage if they leak into the surrounding tissues. Monitoring for signs of extravasation such as swelling, pain, or redness is crucial to prevent tissue damage and ensure prompt intervention if extravasation occurs. Choices B, C, and D are incorrect because monitoring capillary refill, applying a topical anesthetic for burning, and explaining temporary burning do not directly address the risk of extravasation associated with vesicant chemotherapeutic agents.

3. A nurse is preparing to administer an intramuscular (IM) injection to a client. What is the most appropriate site to use for an IM injection in an adult?

• A. Dorsal gluteal muscle
• B. Vastus lateralis muscle
• C. Rectus femoris muscle
• D. Deltoid muscle

Correct answer: B

Rationale: The correct answer is B: Vastus lateralis muscle. The vastus lateralis muscle is a recommended site for IM injections in adults due to its size and accessibility. The dorsal gluteal muscle is not recommended for IM injections in adults due to the proximity to major nerves and blood vessels, increasing the risk of injury. The rectus femoris muscle is not a common site for IM injections in adults. The deltoid muscle is typically used for IM injections in small-volume medications or vaccines, especially in adults.

4. A client with major depression who is taking fluoxetine calls the psychiatric clinic reporting being more agitated, irritable, and anxious than usual. Which intervention should the nurse implement?

• A. Tell the client to have a complete blood count (CBC) drawn
• B. Instruct the client to seek medical attention immediately
• C. Encourage them to take the medication at night with a snack
• D. Explain that these are common side effects of the medication

Correct answer: B

Rationale: Increased agitation, irritability, and anxiety can be signs of serotonin syndrome or other serious side effects, not common side effects of fluoxetine. Instructing the client to seek medical attention immediately is crucial to address any potential serious adverse reactions. Option A is unnecessary as a CBC would not address the symptoms described. Option C is not the priority when serious side effects are suspected. Option D is incorrect as these symptoms should not be dismissed as common side effects.

5. The client had gastric bypass surgery yesterday. Which intervention is most important for the nurse to implement during the first 24 postoperative hours?

• A. Insert an indwelling urinary catheter
• B. Monitor for the appearance of an incisional hernia
• C. Instruct the client to eat small frequent meals
• D. Measure hourly urinary output

Correct answer: D

Rationale: Monitoring hourly urinary output is crucial during the first 24 postoperative hours to assess kidney function, fluid balance, and early detection of complications like dehydration or inadequate kidney perfusion. Inserting an indwelling urinary catheter is not routinely necessary after gastric bypass surgery unless there are specific indications. Monitoring for an incisional hernia is important but not the highest priority in the immediate postoperative period. Instructing the client to eat small frequent meals is essential for long-term dietary management after gastric bypass surgery, but not the most critical intervention during the initial 24 hours.

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