Nursing Elites

1. A client with IV fluids has developed redness and warmth at the IV site. What is the next step the nurse should take?

• A. Apply a cold compress to the IV site
• B. Discontinue the IV and notify the healthcare provider
• C. Monitor the IV site for signs of infection
• D. Increase the IV flow rate to improve circulation

Correct answer: B

Rationale: When a client develops redness and warmth at the IV site, it is indicative of phlebitis, which is inflammation of the vein. The next step for the nurse should be to discontinue the IV and notify the healthcare provider. Applying a cold compress may provide temporary relief but does not address the underlying issue. Monitoring for infection is important, but in this case, the presence of redness and warmth suggests phlebitis, not infection. Increasing the IV flow rate can exacerbate the inflammation and should be avoided.

2. Which lifestyle modification should be emphasized for a client with hypertension?

• A. Increase sodium intake
• B. Reduce caffeine and alcohol intake
• C. Eat carbohydrate-rich meals
• D. Increase protein intake

Correct answer: B

Rationale: The correct answer is to reduce caffeine and alcohol intake for a client with hypertension. Caffeine and alcohol can increase blood pressure, so reducing their intake can help manage hypertension. Increasing sodium intake (Choice A) is not recommended for hypertension as it can lead to fluid retention and increased blood pressure. Eating carbohydrate-rich meals (Choice C) is also not ideal as excessive carbohydrates can contribute to weight gain, which can worsen hypertension. Similarly, increasing protein intake (Choice D) is not a primary focus for managing hypertension unless a specific protein deficiency is present.

3. In the emergency department, a nurse is performing triage for multiple clients following a disaster in the community. To which of the following types of injuries should the nurse assign the highest priority?

• A. Below-the-knee amputation.
• B. 10 cm (4 in) laceration.
• C. Fractured tibia.
• D. 95% full-thickness body burn.

Correct answer: A

Rationale: A below-the-knee amputation requires immediate attention due to the risk of hemorrhage and shock, making it the highest priority. This type of injury can lead to significant blood loss and impaired perfusion, which can be life-threatening if not addressed promptly. While a 10 cm laceration, a fractured tibia, and a 95% full-thickness body burn are serious injuries requiring urgent care, they do not pose the same immediate threat to life as a below-the-knee amputation. The laceration may require suturing to control bleeding and prevent infection, the fractured tibia needs stabilization to prevent further damage and pain, and the burn necessitates immediate management to prevent complications, but they are not as acutely life-threatening as the amputation.

4. What is the most important nursing action when administering IV potassium?

• A. Monitor for decreased urine output
• B. Administer via IV push
• C. Administer slowly and dilute in IV fluids
• D. Ensure the client drinks 500 mL of water before administration

Correct answer: C

Rationale: The most important nursing action when administering IV potassium is to administer it slowly and dilute it in IV fluids. This approach helps prevent irritation and hyperkalemia. Monitoring for decreased urine output (Choice A) is important but not as critical as ensuring the safe administration of IV potassium. Administering potassium via IV push (Choice B) is unsafe and can lead to adverse effects. Ensuring the client drinks water before administration (Choice D) is not directly related to the safe administration of IV potassium.

5. A nurse is preparing a change-of-shift report for an adult female client who is postoperative. Which of the following client information should the nurse include in the report?

• A. Hgb 12.8 g/dl.
• B. Potassium 4.2 mEq/L.
• C. RBC 4.4 million/mm3.
• D. Platelets 100,000/mm3.

Correct answer: D

Rationale: The correct answer is D: "Platelets 100,000/mm3." A platelet count of 100,000/mm3 is low and increases the client's risk for bleeding, which is crucial information to communicate during the change-of-shift report. Choices A, B, and C provide values within normal ranges and are not directly related to the client's postoperative status or risk for complications. Therefore, they are not the priority information to include in the report.

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