Nursing Elites

1. What is the most appropriate action when a patient is experiencing severe dehydration?

• A. Administer IV fluids
• B. Encourage oral fluids
• C. Monitor electrolytes
• D. Perform a neurological exam

Correct answer: A

Rationale: The most appropriate action when a patient is experiencing severe dehydration is to administer IV fluids. This intervention is crucial in rapidly correcting dehydration and restoring fluid balance. Encouraging oral fluids may not be sufficient in cases of severe dehydration where intravenous rehydration is needed. Monitoring electrolytes is important but administering fluids takes precedence in severe dehydration. Performing a neurological exam is not the primary intervention for severe dehydration.

2. A nurse is preparing to administer packed RBCs to a client. Which of the following actions should the nurse take first?

• A. Prime the IV tubing with dextrose 5% in water
• B. Ensure the client's consent is on file
• C. Check the client's identification using two identifiers
• D. Administer the blood through a 22-gauge catheter

Correct answer: C

Rationale: The correct first action for the nurse to take when preparing to administer packed RBCs is to check the client's identification using two identifiers. This step is crucial to ensure that the right blood is given to the right client, preventing any transfusion errors. Priming the IV tubing with dextrose 5% in water and administering the blood through a 22-gauge catheter are important steps but should come after confirming the client's identity. Ensuring the client's consent is on file is also important but is not the immediate priority when preparing to administer packed RBCs.

3. How should a healthcare provider monitor a patient receiving heparin therapy?

• A. Monitor aPTT
• B. Monitor platelet count
• C. Monitor sodium levels
• D. Monitor calcium levels

Correct answer: A

Rationale: The correct answer is to monitor aPTT (activated partial thromboplastin time) when a patient is receiving heparin therapy. aPTT monitoring is essential for assessing the therapeutic effectiveness of heparin, ensuring the patient is within the desired therapeutic range to prevent both clotting and bleeding. Monitoring platelet count (Choice B) is important for assessing for heparin-induced thrombocytopenia but is not the primary monitoring parameter for heparin therapy. Monitoring sodium levels (Choice C) and calcium levels (Choice D) are not directly related to assessing the therapeutic effectiveness or potential side effects of heparin therapy.

4. A nurse is providing discharge teaching to a client who has had a total hip arthroplasty. Which of the following client statements indicates a need for further teaching?

• A. I will avoid sitting in a chair for longer than 30 minutes.
• B. I will avoid crossing my legs when sitting.
• C. I will bend at the hips to pick up items from the floor.
• D. I will avoid using a raised toilet seat.

Correct answer: C

Rationale: The correct answer is C because bending at the hips can dislocate the hip joint in clients who have had a total hip arthroplasty. This movement should be avoided to prevent complications post-surgery. Choices A, B, and D are all correct statements for a client who has had a total hip arthroplasty. Avoiding prolonged sitting, crossing legs, and using a raised toilet seat are all appropriate measures to ensure proper healing and prevent complications.

5. A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets. After securing the client's airway and initiating an IV, which of the following actions should the nurse do next?

• A. Monitor the client's IV site for thrombophlebitis.
• B. Administer flumazenil to the client.
• C. Evaluate the client for further suicidal behavior.
• D. Initiate seizure precautions for the client.

Correct answer: B

Rationale: Administering flumazenil is the priority to reverse the effects of diazepam overdose. Flumazenil is a specific benzodiazepine receptor antagonist that can rapidly reverse the sedative effects of diazepam. Monitoring the IV site for thrombophlebitis is important but not the immediate priority in this situation. Evaluating the client for further suicidal behavior is important for comprehensive care but is not the most urgent action at this moment. Initiating seizure precautions may be necessary, but the priority is to counteract the sedative effects of diazepam with flumazenil.

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