Nursing Elites

1. While caring for a client receiving hemodialysis, which action should the nurse include in the plan of care?

• A. Withhold all medications until after dialysis.
• B. Check the vascular access site for bleeding after dialysis.
• C. Rehydrate with dextrose 5% in water for hypotension.
• D. Give an antibiotic 30 minutes before dialysis.

Correct answer: B

Rationale: The correct action the nurse should include in the plan of care when caring for a client receiving hemodialysis is to check the vascular access site for bleeding after dialysis. This is crucial to monitor for any signs of bleeding or complications at the access site. Withholding all medications until after dialysis (Choice A) is not necessary unless specified for certain medications. Rehydrating with dextrose 5% in water for hypotension (Choice C) is not appropriate for addressing hypotension related to hemodialysis. Giving an antibiotic 30 minutes before dialysis (Choice D) is not typically indicated unless there is a specific medical indication for prophylactic antibiotic use.

2. What is the correct method to teach a patient about self-administration of insulin?

• A. Inject into the upper arm
• B. Rotate injection sites
• C. Use a 45-degree angle for injection
• D. Use a 90-degree angle for injection

Correct answer: D

Rationale: The correct method to teach a patient about self-administration of insulin is to use a 90-degree angle for injection. This angle ensures proper subcutaneous administration of insulin, which is essential for effective absorption. Injecting into the upper arm (Choice A) is not recommended for insulin administration. While rotating injection sites (Choice B) is important to prevent lipodystrophy, the angle of injection is crucial for proper insulin delivery. Using a 45-degree angle (Choice C) is more suitable for intramuscular injections, not for subcutaneous insulin injections.

3. A nurse is assessing a client who is experiencing a panic attack. Which of the following findings should the nurse expect?

• A. Bradycardia.
• B. Hypotension.
• C. Chest pain.
• D. Dilated pupils.

Correct answer: D

Rationale: During a panic attack, the sympathetic nervous system is activated, leading to physiological responses such as dilated pupils. Bradycardia (slow heart rate) and hypotension (low blood pressure) are not typically associated with panic attacks. While chest pain can occur during a panic attack due to rapid breathing and muscle tension, dilated pupils are a more specific finding related to sympathetic activation in this context.

4. A nurse is preparing to insert an IV catheter for a client. Which of the following actions should the nurse take?

• A. Apply a tourniquet above the insertion site
• B. Shave the area around the insertion site
• C. Insert the catheter at a 15-degree angle
• D. Use an 18-gauge needle for insertion

Correct answer: C

Rationale: The correct answer is to insert the catheter at a 15-degree angle. This angle allows for easier venous access by ensuring proper catheter placement into the vein. Applying a tourniquet above the insertion site can help distend the vein for better visualization but is not the immediate action required for the insertion process. Shaving the area around the insertion site is not necessary unless there is excessive hair that may interfere with the insertion. Using an 18-gauge needle for insertion is a specific detail related to the equipment rather than the technique of insertion.

5. A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian.

• A. A client who has a prescription for warfarin and states, 'I will need to limit how much spinach I eat.'
• B. A client who has gout and states, 'I can continue to eat anchovies on my pizza.'
• C. A client who has a prescription for spironolactone and states, 'I will reduce my intake of foods that contain potassium.'
• D. A client who has osteoporosis and states, 'I'll plan to take my calcium carbonate with a full glass of water.'

Correct answer: C

Rationale: The correct answer is C. Spironolactone is a potassium-sparing diuretic, which means it helps the body retain potassium and excrete sodium and water. Therefore, clients on spironolactone should reduce their intake of foods high in potassium to prevent hyperkalemia. Choices A, B, and D are incorrect because limiting spinach intake due to warfarin, eating anchovies with gout, and taking calcium carbonate with water for osteoporosis do not directly relate to the medication's side effects or dietary restrictions associated with spironolactone.

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