Nursing Elites

1. A nurse is caring for a client who has a serum calcium level of 14 mg/dL. Which provider order should the nurse implement first?

• A. Encourage oral fluid intake.
• B. Connect the client to a cardiac monitor.
• C. Assess urinary output.
• D. Administer oral calcitonin (Calcimar).

Correct answer: A

Rationale: The correct answer is to encourage oral fluid intake. With a serum calcium level of 14 mg/dL, the client is at risk of hypercalcemia. Encouraging oral fluid intake helps to promote hydration and can help prevent further elevation of calcium levels. Connecting the client to a cardiac monitor (Choice B) is important but not the first priority in this situation. Assessing urinary output (Choice C) is relevant but does not address the immediate concern of high serum calcium levels. Administering oral calcitonin (Calcimar) (Choice D) may be a treatment option later, but the first step should be to address hydration.

2. The nurse who assesses the patient's peripheral IV site and notes edema around the insertion site will document which complication related to IV therapy?

• A. Air emboli
• B. Phlebitis
• C. Infiltration
• D. Fluid overload

Correct answer: C

Rationale: Infiltration is the administration of non-vesicant solution or medication into the surrounding tissue. This can occur when the IV cannula dislodges or perforates the vein's wall. Infiltration is characterized by edema around the insertion site, leakage of IV fluid from the insertion site, discomfort, and coolness in the area of infiltration, and a significant decrease in the flow rate. Air emboli (Choice A) involves air entering the bloodstream. Phlebitis (Choice B) is inflammation of a vein. Fluid overload (Choice D) is an excessive volume of fluid in the circulatory system.

3. . A nurse is planning care for a nephrology patient with a new nursing graduate. The nurse states, A patient in renal failure partially loses the ability to regulate changes in pH. What is the cause of this partial inability?

• A. The kidneys regulate and reabsorb carbonic acid to change and maintain pH.
• B. The kidneys buffer acids through electrolyte changes
• C. The kidneys regenerate and reabsorb bicarbonate to maintain a stable pH.
• D. The kidneys combine carbonic acid and bicarbonate to maintain a stable pH.

Correct answer: C

Rationale:

4. The chief mechanism for maintaining fluid balance is to:

• A. adjust fluid intake so it equals fluid output.
• B. adjust fluid intake so it is slightly above fluid output.
• C. adjust fluid output so it equals fluid input.
• D. adjust fluid intake so it is slightly below fluid output.

Correct answer: C

Rationale: The correct answer is C: 'adjust fluid output so it equals fluid input.' Maintaining fluid balance involves ensuring that the amount of fluid lost through processes like urination, sweating, and respiration equals the amount of fluid taken in. This ensures that the body stays properly hydrated. Choices A, B, and D are incorrect because they do not focus on the balance between fluid input and output, which is crucial for maintaining proper fluid balance. By adjusting fluid output to equal fluid input, the body can regulate hydration levels effectively, preventing dehydration or overhydration.

5. Under normal circumstances, the kidneys provide the greatest means of water loss. Which organ provides the second greatest means of water loss?

• A. Skin
• B. Lungs
• C. Intestines
• D. Muscles

Correct answer: A

Rationale: The correct answer is A: Skin. After the kidneys, the skin is the second largest route of water loss through perspiration. Choice B, Lungs, is incorrect as the lungs primarily exchange gases and do not play a significant role in water loss. Choice C, Intestines, is also incorrect as water loss through the intestines is minimal since most water is reabsorbed during digestion. Choice D, Muscles, is incorrect as muscles are not a major source of water loss in the body.

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