Nursing Elites

1. A nurse in the emergency department is caring for a client who has full-thickness burns of the thorax and upper torso. After securing the client's airway, which of the following is the nurse's priority intervention?

• A. Providing pain management.
• B. Offering emotional support.
• C. Preventing infection.
• D. Initiating IV fluids.

Correct answer: D

Rationale: After securing the airway, initiating IV fluids is the priority to prevent hypovolemic shock in clients with severe burns. IV fluids help maintain circulating volume and prevent a drop in blood pressure due to fluid loss. Providing pain management, offering emotional support, and preventing infection are important aspects of care but are secondary to ensuring adequate fluid resuscitation in clients with severe burns.

2. What is the role of a nurse in managing a patient with kidney disease?

• A. Monitor blood pressure and provide dietary education
• B. Monitor urine output and provide IV fluids
• C. Administer diuretics and restrict fluid intake
• D. Monitor for cardiac arrhythmias and provide dialysis

Correct answer: A

Rationale: The correct answer is A. Nurses play a crucial role in managing patients with kidney disease by monitoring blood pressure and providing essential dietary education. This helps in maintaining kidney function and overall health. Choice B is incorrect because monitoring urine output and providing IV fluids are tasks usually performed by healthcare providers such as physicians or specialized staff. Choice C is incorrect as administering diuretics and restricting fluid intake are typically prescribed by a physician, and nurses may assist in monitoring the effects. Choice D is incorrect as monitoring for cardiac arrhythmias and providing dialysis are tasks that are usually overseen by healthcare providers with specialized training in cardiology and nephrology.

3. A nurse is admitting a client who has anorexia nervosa. Which of the following is an expected finding?

• A. Iron 90 mcg/dl.
• B. Prealbumin 10 mcg/dl.
• C. Serum creatinine 0.8 mg/dl.
• D. Calcium 9.5 mg/dl.

Correct answer: B

Rationale: Corrected Rationale: Low prealbumin levels are indicative of malnutrition, which is common in individuals with anorexia nervosa. Iron levels, serum creatinine, and calcium levels are not typically affected in the same way by anorexia nervosa, making choices A, C, and D incorrect.

4. A nurse is caring for a client receiving IV fluids. Which of the following should the nurse do upon noticing phlebitis at the IV site?

• A. Apply a cold compress to the site
• B. Notify the provider immediately
• C. Remove the IV catheter and restart it in another location
• D. Monitor the site for signs of infection

Correct answer: C

Rationale: Upon noticing phlebitis at the IV site, the nurse should remove the IV catheter and restart it in another location. Phlebitis is inflammation of the vein, and leaving the IV catheter in place can lead to further complications such as infection. Applying a cold compress (Choice A) may provide temporary relief but does not address the underlying issue. Notifying the provider immediately (Choice B) is important, but the immediate action to prevent complications is to remove the IV catheter. Monitoring the site for signs of infection (Choice D) is necessary, but the priority action is to remove and reinsert the IV catheter to prevent worsening of the phlebitis.

5. A nurse is preparing to administer a medication to a client. The client states, 'I'm sick of all these medications, and I'm not taking any more today!' Which of the following actions should the nurse take?

• A. Ask the client to discuss their feelings
• B. Explain the importance of the medications
• C. Document the refusal and withhold the medication
• D. Inform the client of the possible consequences of refusal

Correct answer: D

Rationale: When a client refuses medication, the nurse should inform the client of the possible consequences of refusal. This action helps the client understand the risks associated with not taking the medication. Asking the client to discuss their feelings (choice A) is important but should follow after informing them of the consequences. Explaining the importance of the medications (choice B) might not address the immediate concern of the client. Documenting the refusal and withholding the medication (choice C) should be done after informing the client of the consequences and attempting to address their concerns.

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