Nursing Elites

1. A nurse is planning care for a client who is receiving hemodialysis via an AV fistula. Which of the following interventions should the nurse include in the plan of care?

• A. Avoid taking blood pressures on the arm with the AV fistula.
• B. Check the fistula site daily for pallor.
• C. Place a warm compress over the fistula site every 4 hours.
• D. Keep the client's arm elevated on two pillows.

Correct answer: A

Rationale: The correct intervention is to avoid taking blood pressures on the arm with the AV fistula. This is crucial to prevent complications such as damage to the fistula. Checking the fistula site for pallor is not as important as avoiding blood pressures on the affected arm. Placing warm compresses over the fistula site is not recommended as it can increase the risk of infection. Keeping the client's arm elevated on two pillows is not necessary for the care of an AV fistula.

2. A healthcare professional is collecting data from a client who has iron deficiency anemia. Which of the following findings should the healthcare professional expect?

• A. Increased energy
• B. Easy bruising
• C. Pale conjunctiva
• D. Weight gain

Correct answer: C

Rationale: Pale conjunctiva is a common sign of iron deficiency anemia due to reduced hemoglobin levels. This results in decreased oxygen-carrying capacity, leading to tissue hypoxia and pallor. 'Increased energy' (choice A) is not typically associated with iron deficiency anemia, as fatigue and weakness are common symptoms. 'Easy bruising' (choice B) is more characteristic of platelet disorders or vitamin deficiencies rather than iron deficiency anemia. 'Weight gain' (choice D) is not a typical finding in iron deficiency anemia; in fact, weight loss is more common due to decreased appetite and overall weakness.

3. How should a healthcare provider manage a patient with hyperkalemia?

• A. Administer insulin and glucose
• B. Restrict potassium intake
• C. Monitor ECG
• D. All of the above

Correct answer: D

Rationale: In managing hyperkalemia, it is essential to administer insulin and glucose to shift potassium into the cells, restrict potassium intake to prevent further elevation of serum levels, and monitor the ECG for signs of potassium-induced cardiac effects. Therefore, the correct answer is D, as all of the provided actions are important in the management of hyperkalemia. Choice A alone is not sufficient as it only addresses shifting potassium intracellularly without preventing further elevation. Choice B alone is not enough as it does not address the immediate need to lower serum potassium levels. Choice C alone is insufficient as it only monitors for cardiac effects without addressing potassium levels or shifting mechanisms.

4. When caring for a client with a wound infection, what is the most important nursing action?

• A. Change the dressing every 4 hours
• B. Perform a wound culture before administering antibiotics
• C. Cleanse the wound with alcohol-based solutions
• D. Apply a wet-to-dry dressing to the wound

Correct answer: B

Rationale: Performing a wound culture before administering antibiotics is crucial in identifying the specific infecting organism and choosing the most effective antibiotic treatment. Changing the dressing every 4 hours (choice A) may be too frequent and can disrupt the wound healing process. Cleansing the wound with alcohol-based solutions (choice C) can be too harsh and may delay healing. Applying a wet-to-dry dressing (choice D) can cause trauma to the wound bed and is not recommended for infected wounds.

5. A client is being taught by a nurse how to ascend stairs while using crutches. Which of the following actions should the nurse instruct the client to take first?

• A. Move both crutches up first
• B. Step up with the unaffected leg first
• C. Lean forward on the crutches before stepping up
• D. Hold onto the handrail for support

Correct answer: B

Rationale: The correct answer is to instruct the client to step up with the unaffected leg first. This action is crucial as it ensures proper balance and safety when ascending stairs with crutches. By stepping up with the unaffected leg first, the client can maintain stability and reduce the risk of falls. Choices A, C, and D are incorrect. Moving both crutches up first (Choice A) may lead to imbalance and difficulty in weight distribution. Leaning forward on the crutches before stepping up (Choice C) can compromise the client's stability and increase the risk of falling. While holding onto the handrail for support (Choice D) is important, stepping up with the unaffected leg first takes precedence to establish a secure and safe movement up the stairs.

Similar Questions