Nursing Elites

1. The nurse is preparing to insert a peripheral IV catheter into a patient who will require fluids and IV antibiotics. How should the nurse always start the process of insertion?

• A. Leave one hand ungloved to assess the site.
• B. Cleanse the skin with normal saline.
• C. Ask the patient about allergies to latex or iodine.
• D. Remove excessive hair from the selected site.

Correct answer: C

Rationale:

2. You are working on a burns unit, and one of your acutely ill patients is exhibiting signs and symptoms of third spacing. Based on this change in status, you should expect the patient to exhibit signs and symptoms of what imbalance?

• A. Metabolic alkalosis
• B. Hypermagnesemia
• C. Hypercalcemia
• D. Hypovolemia

Correct answer: D

Rationale: Third spacing refers to the loss of fluid from the intravascular space into the interstitial or third space, leading to a decrease in circulating blood volume. This condition results in hypovolemia, which is characterized by decreased blood volume. Metabolic alkalosis, hypermagnesemia, and hypercalcemia are not directly associated with third spacing. Metabolic alkalosis is an acid-base imbalance, hypermagnesemia is an excess of magnesium in the blood, and hypercalcemia is an excess of calcium in the blood, none of which are the primary concerns in cases of third spacing.

3. After teaching a client to increase dietary potassium intake, a nurse assesses the client's understanding. Which dietary meal selection indicates the client correctly understands the teaching?

• A. Toasted English muffin with butter and blueberry jam, and tea with sugar
• B. Two scrambled eggs, a slice of white toast, and a half cup of strawberries
• C. Sausage, one slice of whole wheat toast, half cup of raisins, and a glass of milk
• D. Bowl of oatmeal with brown sugar, a half cup of sliced peaches, and coffee

Correct answer: C

Rationale: Choice C is the correct answer as it includes foods high in potassium, such as raisins, whole wheat toast, and milk. Potassium is essential for various bodily functions, including maintaining proper heart and muscle function. Choices A, B, and D do not contain significant sources of potassium. Choice A consists mainly of carbohydrates and sugar, choice B focuses on protein and carbohydrates, and choice D provides carbohydrates and some fruit but lacks high-potassium options like in choice C.

4. A nurse assesses a client who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L. What action should the nurse take next?

• A. Assess clients rate, rhythm, and depth of respiration.
• B. Measure the clients pulse and blood pressure.
• C. Document the findings and continue to monitor.
• D. Notify the physician as soon as possible.

Correct answer: A

Rationale:

5. A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse?

• A. Redness at the catheter insertion site
• B. Report of headache and stiff neck
• C. Temperature of 100.1 F (37.8 C)
• D. Pain rating of 8 on a scale of 0 to 10

Correct answer: B

Rationale:

Similar Questions