Nursing Elites

1. A client receiving IV fluids has developed phlebitis. What action should the nurse take next after removing the IV catheter?

• A. Place a warm compress over the IV site
• B. Record the findings in the client's chart
• C. Notify the client's primary care provider
• D. Insert a new IV catheter

Correct answer: A

Rationale: After removing an IV catheter due to phlebitis, the next step is to apply a warm compress over the IV site. This helps reduce inflammation and discomfort for the client. Recording the findings in the client's chart is important for documentation purposes but not the immediate next step. Notifying the client's primary care provider may be necessary depending on the severity of the phlebitis, but it is not the initial action. Inserting a new IV catheter is not appropriate until the phlebitis has resolved.

2. A client with peripheral arterial disease (PAD) is being taught about foot care by a nurse. Which of the following instructions should the nurse include?

• A. Apply lotion between the toes
• B. Wear shoes that fit properly
• C. Walk barefoot at home
• D. Apply ice to the feet daily

Correct answer: B

Rationale: The correct answer is B: 'Wear shoes that fit properly.' In peripheral arterial disease (PAD), it is crucial to wear shoes that fit well to prevent foot injuries. Choice A is incorrect because applying lotion between the toes can increase the risk of infection. Choice C is incorrect since walking barefoot at home can lead to injuries, especially in individuals with PAD. Choice D is incorrect as applying ice to the feet daily can further reduce blood flow to the extremities, worsening the condition in PAD.

3. A nurse is reviewing the plan of care for a client who is receiving total parenteral nutrition (TPN). Which of the following interventions should the nurse include?

• A. Monitor daily fluid intake
• B. Monitor blood glucose levels
• C. Measure intake and output
• D. Administer insulin as prescribed

Correct answer: B

Rationale: The correct answer is B: 'Monitor blood glucose levels.' When a client is receiving total parenteral nutrition (TPN), which has a high glucose content, it is crucial to monitor blood glucose levels closely to prevent hyperglycemia. Monitoring daily fluid intake (Choice A) is important in other contexts but is not directly related to TPN administration. Measuring intake and output (Choice C) is a general nursing intervention that is relevant for assessing fluid balance but is not specific to TPN administration. Administering insulin as prescribed (Choice D) may be necessary for clients with hyperglycemia, but this intervention is based on the blood glucose monitoring results and the healthcare provider's orders, not a standard intervention for all clients receiving TPN.

4. What is the correct procedure for taking a telephone order from a provider?

• A. State patient name, drug, dose, route, frequency, and read back the order
• B. State the medication and ask for a witness to listen to the order
• C. Write down the order and verify with the provider within 12 hours
• D. Have the provider verify the order during the next in-person visit

Correct answer: A

Rationale: The correct procedure for taking a telephone order from a provider is to state the patient's name, drug, dose, route, frequency, and then read back the order to ensure accuracy. This process helps in preventing errors and ensures that all relevant information is correctly documented. Choice B is incorrect because having a witness listen to the order is not a standard practice and may not guarantee accuracy. Choice C is incorrect as verifying the order within 12 hours may lead to delays in patient care. Choice D is incorrect because waiting for the provider to verify the order during the next in-person visit could result in a significant delay in administering necessary medication.

5. How should a healthcare provider assess a patient with potential diabetic ketoacidosis (DKA)?

• A. Monitor blood glucose and check for ketones in urine
• B. Administer insulin and provide fluids
• C. Administer potassium and check for electrolyte imbalance
• D. Administer sodium bicarbonate and monitor urine output

Correct answer: A

Rationale: Correct answer: To assess a patient with potential diabetic ketoacidosis (DKA), healthcare providers should monitor blood glucose and check for ketones in the urine. Elevated blood glucose levels and the presence of ketones in urine are indicative of DKA. Choice B is incorrect because administering insulin and providing fluids are treatments for DKA rather than assessment measures. Choice C is incorrect as administering potassium and checking for electrolyte imbalance are interventions related to managing DKA complications, not initial assessment. Choice D is incorrect because administering sodium bicarbonate and monitoring urine output are not primary assessment actions for DKA.

Similar Questions