Nursing Elites

1. A healthcare provider is caring for a client who is receiving IV therapy via a peripheral catheter. The healthcare provider should identify that which of the following findings is an indication of infiltration?

• A. Redness at the infusion site
• B. Edema at the infusion site
• C. Warmth at the infusion site
• D. Oozing of blood at the infusion site

Correct answer: B

Rationale: Edema at the infusion site is an indication of infiltration, where fluid leaks into the surrounding tissues causing swelling. This can compromise the delivery of medication and fluids, potentially leading to complications. Redness, warmth, and oozing of blood are more suggestive of inflammation or infection rather than infiltration. Infiltration requires prompt recognition and intervention to prevent further issues with the IV therapy.

2. A client with a new diagnosis of hypertension is receiving teaching from a healthcare provider. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will decrease my intake of potassium.
• B. I will increase my intake of vitamin K.
• C. I will decrease my intake of sodium.
• D. I will increase my intake of magnesium.

Correct answer: C

Rationale: The correct answer is C: 'I will decrease my intake of sodium.' Lowering sodium intake is essential in managing hypertension as it helps reduce blood pressure levels. Excess sodium can lead to fluid retention and increased blood volume, putting more strain on the heart and blood vessels. Therefore, this response indicates an understanding of the teaching provided. Choices A, B, and D are incorrect because decreasing potassium intake, increasing vitamin K intake, and increasing magnesium intake are not primary dietary modifications recommended for hypertension. While potassium and magnesium can be beneficial for overall health, reducing sodium intake is the key dietary change to manage hypertension effectively.

3. What action should be taken to prevent respiratory complications in a client who is postoperative?

• A. Encourage the use of an incentive spirometer.
• B. Restrict fluid intake.
• C. Place the client in a supine position.
• D. Administer a cough suppressant.

Correct answer: A

Rationale: Encouraging the use of an incentive spirometer is crucial in preventing respiratory complications postoperatively. The incentive spirometer helps the client perform deep breathing exercises, which can prevent atelectasis (lung collapse) and promote lung expansion. This, in turn, reduces the risk of respiratory complications such as pneumonia. Restricting fluid intake, placing the client in a supine position, and administering a cough suppressant are not appropriate actions for preventing respiratory complications in a postoperative client.

4. When teaching a client with a new diagnosis of hepatitis about dietary management, which of the following statements should the nurse include?

• A. Increase your intake of high-protein foods.
• B. Decrease your intake of high-protein foods.
• C. Avoid foods that contain lactose.
• D. Increase your intake of dairy products.

Correct answer: B

Rationale: For a client with hepatitis, it is important to decrease the intake of high-protein foods. High-protein foods can be harder for the liver to process and may exacerbate symptoms or contribute to liver damage. Recommending a diet with moderate protein intake is beneficial for managing symptoms and promoting liver health. Choice A is incorrect as increasing high-protein foods can strain the liver. Choice C is not directly related to hepatitis unless there is an intolerance present. Choice D is also incorrect because increasing dairy products may not be suitable for all individuals with hepatitis, especially if there are underlying liver conditions that could be aggravated by certain dairy components.

5. A client has a new prescription for total parenteral nutrition (TPN). Which of the following actions should the nurse plan to take?

• A. Obtain a random blood glucose daily.
• B. Change the IV tubing every 72 hours.
• C. Apply a new dressing to the IV site every 24 hours.
• D. Weigh the client weekly.

Correct answer: A

Rationale: When a client is on total parenteral nutrition (TPN), monitoring blood glucose levels daily is crucial to manage and detect complications like hyperglycemia, which can occur due to the high glucose content in TPN solutions. Regular blood glucose monitoring helps the healthcare team adjust the TPN infusion rate to maintain optimal glucose levels and prevent adverse events. Choices B, C, and D are incorrect because changing IV tubing every 72 hours, applying a new dressing to the IV site every 24 hours, and weighing the client weekly are not specific actions directly related to monitoring and managing the effects of TPN, particularly in relation to glucose levels.

Similar Questions