Nursing Elites

1. A nurse is assessing clients who have intravenous therapy prescribed. Which assessment finding for a client with a peripherally inserted central catheter (PICC) requires immediate attention?

• A. The initial site dressing is 3 days old.
• B. The PICC was inserted 4 weeks ago.
• C. A securement device is absent.
• D. Upper extremity swelling is noted.

Correct answer: D

Rationale:

2. When selecting a site on the hand or arm for insertion of an IV catheter, the nurse should:

• A. Choose a proximal site.
• B. Choose a distal site.
• C. Have the patient hold their arm in a dependent position.
• D. Leave the tourniquet on for no longer than 2 minutes.

Correct answer: B

Rationale: When selecting a site for insertion of an IV catheter, the nurse should choose a distal site, not a proximal site. Opting for a distal site ensures that upper veins remain available for future cannulations. Instructing the patient to hold their arm in a dependent position can enhance blood flow, aiding in the procedure. It is crucial never to leave a tourniquet on for more than 2 minutes as prolonged restriction can lead to complications. Choice A is incorrect because a proximal site is not preferred for IV insertion. Choice C is incorrect as having the patient hold their arm over their head is not necessary and may impede proper blood flow. Choice D is incorrect as leaving the tourniquet on for at least 5 minutes is excessive and can be harmful.

3. Which negative ion is most important in intracellular fluid?

• A. Phosphate ions.
• B. Protein molecules.
• C. Chlorine.
• D. Phosphate ions and protein molecules.

Correct answer: D

Rationale: Intracellular fluid contains phosphate ions and protein molecules as essential anions. Phosphate ions play a crucial role in various cellular processes, including energy transfer. Proteins, being large molecules with negative charges, also contribute significantly to the negative ion concentration within cells. Chlorine is primarily an extracellular anion and is not as prominent as phosphate ions and proteins within intracellular fluid, making it a less important negative ion in this context. Therefore, the correct answer is D because both phosphate ions and protein molecules are crucial negative ions in intracellular fluid.

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. The nurse is caring for a patient who is diaphoretic from a fever. The amount of sodium excreted in the urine will:

• A. Decrease
• B. Increase
• C. Remain unchanged
• D. Fluctuate

Correct answer: A

Rationale: Increased sweating (diaphoresis) causes the loss of sodium and other electrolytes from the body. As a result, the body tries to conserve sodium, leading to a decrease in the amount of sodium excreted in the urine. Choice B is incorrect because increased sweating results in sodium loss, not retention. Choice C is incorrect because with increased sweating, there is a need to conserve sodium, leading to a decrease in its excretion. Choice D is incorrect as there is a clear physiological response to sweating that results in a more consistent decrease in sodium excretion.

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