Nursing Elites

1. The client has received IV solutions for three (3) days through a 20-gauge IV catheter placed in the left cephalic vein. On morning rounds, the nurse notes the IV site is tender to palpation and a red streak has formed. Which action should the nurse implement first?

• A. Start a new IV in the right hand.
• B. Discontinue the intravenous line.
• C. Complete an incident record.
• D. Place a warm washcloth over the site.

Correct answer: B

Rationale: The first action should be to discontinue the intravenous line to prevent further complications such as infection or thrombophlebitis. Starting a new IV in the right hand is not the priority as addressing the current issue is important. Completing an incident record can be done after addressing the immediate concern of the IV site. Placing a warm washcloth over the site does not address the red streak and tenderness, which may indicate an infection that requires discontinuation of the IV line.

2. A client with hyperthyroidism is receiving radioactive iodine therapy. The nurse should monitor for which of the following side effects?

• A. Hypothyroidism
• B. Hyperkalemia
• C. Hyponatremia
• D. Hypercalcemia

Correct answer: A

Rationale: The correct answer is A: Hypothyroidism. Radioactive iodine therapy is used to treat hyperthyroidism by destroying thyroid tissue and reducing hormone production. This can lead to an underactive thyroid, resulting in hypothyroidism. Hyperkalemia (choice B) is an elevated potassium level, usually not associated with radioactive iodine therapy. Hyponatremia (choice C) is a low sodium level, which is also not a common side effect of this therapy. Hypercalcemia (choice D) is an elevated calcium level, unrelated to radioactive iodine therapy for hyperthyroidism.

3. The client with newly diagnosed diabetes mellitus is being taught about managing blood glucose levels. Which statement indicates a need for further teaching?

• A. I will rotate my insulin injection sites to avoid tissue damage.
• B. I will monitor my blood glucose levels before each meal.
• C. I can eat unlimited fruit as it is healthy.
• D. I should carry a fast-acting carbohydrate with me at all times.

Correct answer: C

Rationale: Choice C indicates a need for further teaching because stating 'I can eat unlimited fruit as it is healthy' is incorrect. While fruits are healthy, they also contain natural sugars that can affect blood glucose levels. Portion control is crucial to managing blood glucose levels effectively. Choices A, B, and D demonstrate correct understanding. Rotating insulin injection sites helps prevent tissue damage, monitoring blood glucose levels before meals aids in managing diabetes effectively, and carrying a fast-acting carbohydrate is essential to treat hypoglycemia promptly.

4. The client has syndrome of inappropriate antidiuretic hormone (SIADH). Which intervention is most appropriate?

• A. Encourage increased fluid intake
• B. Administer hypertonic saline
• C. Monitor for signs of dehydration
• D. Restrict oral fluids

Correct answer: D

Rationale: The correct intervention for a client with syndrome of inappropriate antidiuretic hormone (SIADH) is to restrict oral fluids. This is because SIADH leads to excessive production of antidiuretic hormone, causing water retention and dilutional hyponatremia. By restricting oral fluids, the nurse helps prevent further water retention and imbalance of electrolytes. Encouraging increased fluid intake (Choice A) would exacerbate the condition by further increasing fluid retention. Administering hypertonic saline (Choice B) is not the primary treatment for SIADH, as it may worsen the imbalance. Monitoring for signs of dehydration (Choice C) is not appropriate since SIADH leads to water retention, not dehydration.

5. A nursing student needs to administer potassium chloride intravenously as prescribed to a client with hypokalemia. The nursing instructor determines that the student is unprepared for this procedure if the student states that which of the following is part of the plan for preparation and administration of the potassium?

• A. Obtaining a controlled IV infusion pump
• B. Monitoring urine output during administration
• C. Diluting an appropriate amount of normal saline
• D. Preparing the medication for bolus administration

Correct answer: D

Rationale: The correct answer is preparing the medication for bolus administration (Choice D). Potassium should never be administered as a bolus because it can cause cardiac arrest. It must always be diluted and given slowly. Obtaining a controlled IV infusion pump (Choice A) is essential for accurate delivery, monitoring urine output during administration (Choice B) helps assess the client's response, and diluting an appropriate amount of normal saline (Choice C) is necessary to prevent irritation and ensure safe administration.

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