when administering intravenous electrolyte solution the nurse should take which of the following precautions when administering intravenous electrolyte solution the nurse should take which of the following precautions
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NCLEX PN 2023 Quizlet

1. When administering intravenous electrolyte solution, which of the following precautions should the nurse take?

Correct answer: Prevent infiltration of calcium, which causes tissue necrosis and sloughing.

Rationale: When administering intravenous electrolyte solutions, it is crucial to prevent infiltration of calcium to avoid tissue necrosis and sloughing. Hypertonic solutions should be infused cautiously (Choice A) to prevent adverse effects. The correct amount of potassium to be mixed in a liter of fluid is no more than 60 mEq, making Choice B incorrect. While monitoring the client’s digitalis dosage for potential adjustments due to IV calcium administration is important, the statement suggesting an increased dosage is incorrect as IV calcium diminishes digitalis's action, making Choice D incorrect.

2. In a community hospital, a nurse is employed as a staff nurse and is supervised by a nurse manager. The nurse understands that in this position, the term authority most appropriately refers to which description?

Correct answer: The official power to ensure that an organizational decision is enforced

Rationale: The term authority refers to the official power of an individual to approve or command an action or to ensure that a decision is enforced. In the context of the nurse's position supervised by a nurse manager, having authority means having the official power to ensure that organizational decisions are carried out. Choice A, accepting responsibility for the actions of others, is more related to accountability rather than authority. Choice C, bearing the legal responsibility for others’ performance of tasks, is more about legal liability rather than authority. Choice D, taking responsibility for what staff members do, is similar to choice A and is more about accountability rather than having the official power to enforce decisions. Therefore, the correct answer is B as it directly relates to the concept of authority in the context described.

3. A client with schizophrenia and his parents are meeting with the nurse. One of the young man's parents says to the nurse, 'We were stunned when we learned that our son had schizophrenia. He was no different from his older brother when they were growing up. Now he's had another relapse, and we can't understand why he stopped his medication.' Which response by the nurse is appropriate?

Correct answer: Asking the client, 'How can we help you to take your medicine or to tell us when you're having problems so that your medication can be adjusted?'

Rationale: The appropriate response is to ask the client how they can be helped in taking their medication or sharing problems to adjust the medication. This approach promotes direct communication with the client, allowing for better assessment of the situation and understanding the client's motivations and behaviors. It also encourages openness and mutual communication between the client and their family. Choice A provides important information about noncompliance as a common reason for relapse but lacks a therapeutic approach by not facilitating emotional expression. Choice B uses a threatening message and is nontherapeutic. Choice D prematurely analyzes the client's motivations without sufficient assessment and lacks a therapeutic communication style.

4. What is one characteristic of human immunodeficiency virus (HIV)?

Correct answer: C

Rationale: The correct answer is C. HIV integrates its genetic material into the host cell's DNA. The virus uses the enzyme reverse transcriptase to make a DNA copy of its RNA, which is then inserted into the genetic material of the infected cell. Choice A is incorrect because the presence of antibodies does not indicate immunity to HIV but rather exposure to the virus. Choice B is incorrect as HIV replication occurs intracellularly, inside the host cell. Choice D is irrelevant to the characteristics of HIV.

5. The nurse is caring for a preschool child who is being treated in the hospital for respiratory syncytial virus (RSV). In planning the client’s care, the nurse should recognize that the child is likely to view this illness as?

Correct answer: Punishment.

Rationale: The correct answer is A: Punishment. Preschool children often see illness as a form of punishment, especially when they are unable to understand the cause of their sickness. This perception is rooted in their limited cognitive abilities and understanding of health concepts. Choices B, C, and D are incorrect because preschool children are less likely to associate illness with disturbance to body image, rejection from parents, or changes in routine with friends. These options are not developmentally appropriate for how preschoolers typically interpret illness.

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