Nursing Elites

1. An older client is receiving an IV of 5% dextrose in 0.45% normal saline at 75 mL/hour. Which assessment finding indicates to the nurse that the client is developing a complication from this therapy?

• A. Capillary refill takes > 3 seconds.
• B. Episodes of vertigo and loss of balance.
• C. Average daily output of 1200 ml.
• D. Pulse rate of 110 beats/minute and dyspnea upon exertion.

Correct answer: D

Rationale: The correct answer is D. Tachycardia and dyspnea are signs of fluid overload, which is a potential complication of IV fluid therapy. Choices A, B, and C are not directly related to fluid overload and are not typical signs of complications associated with the IV fluid therapy being administered.

2. What is the best position for a client experiencing a nosebleed?

• A. Sitting up and leaning forward
• B. Lying flat with a pillow under the head
• C. Sitting up and leaning back
• D. Lying on the side with the head elevated

Correct answer: A

Rationale: The best position for a client experiencing a nosebleed is sitting up and leaning forward. This position helps prevent blood from flowing down the throat and reduces the risk of aspiration. Choice B is incorrect as lying flat can lead to blood flowing down the throat. Choice C is also incorrect because leaning back may cause blood to flow backward into the throat. Choice D is incorrect as lying on the side with the head elevated is not the optimal position to manage a nosebleed effectively.

3. An adult client who received partial-thickness and full-thickness burns over 40% of the body in a house fire is admitted to the inpatient burn unit.

• A. Normal Saline
• B. Lactated Ringer’s
• C. 5% Dextrose in water
• D. 0.45% Sodium Chloride

Correct answer: B

Rationale: In burn patients, Lactated Ringer's solution is preferred over other options as it helps in restoring fluid and electrolyte balance effectively. Lactated Ringer's contains electrolytes (sodium, potassium, calcium) that closely mimic the body's natural composition, making it a suitable choice for fluid resuscitation in burn injuries. Normal Saline (Choice A) lacks electrolytes like potassium and calcium, which are essential in burn management. 5% Dextrose in water (Choice C) is a hypotonic solution and is not the ideal choice for fluid resuscitation in burn patients. 0.45% Sodium Chloride (Choice D) is a hypotonic solution mainly used for conditions requiring free water replacement rather than volume expansion needed in burn injuries.

4. A client with hypertension is prescribed a low-sodium diet. Which food should the client avoid?

• A. Fresh fruits
• B. Processed cheese
• C. Whole grain bread
• D. Fresh vegetables

Correct answer: B

Rationale: The correct answer is B: Processed cheese. Processed cheese is high in sodium and should be avoided in a low-sodium diet for clients with hypertension. Fresh fruits, whole grain bread, and fresh vegetables are generally low in sodium and can be part of a healthy diet for clients with hypertension.

5. Parents of a 6-month-old child, who has just been diagnosed with iron deficiency anemia, ask why it was not diagnosed earlier. What would be the best response by the nurse?

• A. Are you sure your child has iron deficiency anemia?
• B. This happens when the maternal stores of iron are depleted at about 6 months.
• C. This anemia is caused by blood loss.
• D. The child may not have had it for a long time.

Correct answer: B

Rationale: The best response by the nurse would be choice B: 'This happens when the maternal stores of iron are depleted at about 6 months.' Iron deficiency anemia becomes apparent at about 6 months of age in a full-term infant when the maternal stores of iron are depleted. Choice A is incorrect because it questions the diagnosis provided by the healthcare provider. Choice C is incorrect because iron deficiency anemia in infants is primarily due to insufficient iron intake rather than blood loss. Choice D is incorrect as iron deficiency anemia typically develops gradually due to inadequate iron intake.

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