Nursing Elites

1. A client at risk for developing hyperkalemia states, 'I love fruit and usually eat it every day, but now I can't because of my high potassium level.' How should the nurse respond?

• A. Potatoes and avocados can be substituted for fruit.
• B. If you cook the fruit, the amount of potassium will be lower.
• C. Berries, cherries, apples, and peaches are low in potassium.
• D. You are correct. Fruit is very high in potassium.

Correct answer: C

Rationale: The correct answer is C. Berries, cherries, apples, and peaches are indeed low in potassium, making them suitable choices for someone at risk for hyperkalemia. Choice A is incorrect because potatoes and avocados are high in potassium and should be avoided in this situation. Choice B is incorrect because cooking fruit does not significantly lower its potassium content. Choice D is incorrect as it provides incorrect information, as not all fruits are very high in potassium.

2. A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention should the nurse implement to prevent injury while in the hospital?

• A. Ask family members to speak quietly to keep the client calm.
• B. Assess urine color, amount, and specific gravity each day.
• C. Encourage the client to drink at least 1 liter of fluids each shift.
• D. Dangle the client on the bedside before ambulating.

Correct answer: D

Rationale: The correct answer is to 'dangle the client on the bedside before ambulating.' This intervention helps prevent orthostatic hypotension, a drop in blood pressure when changing positions, which is crucial in preventing falls and related injuries in older adult clients. Asking family members to speak quietly (Choice A) may help keep the client calm but does not directly address the risk of injury. Assessing urine parameters (Choice B) is important for monitoring hydration status but does not specifically prevent injury. Encouraging increased fluid intake (Choice C) is essential for managing dehydration but does not directly address the risk of injury during ambulation.

3. Which of the following is not considered an extracellular fluid?

• A. Cerebrospinal fluid
• B. The humors of the eye
• C. Lymph
• D. Cerebrospinal fluid and the humors of the eye

Correct answer: D

Rationale: The correct answer is D. Cerebrospinal fluid and the humors of the eye are not considered extracellular fluids. Extracellular fluids are fluids found outside the cells, such as interstitial fluid and lymph. Cerebrospinal fluid is found within the central nervous system, while the humors of the eye (aqueous humor and vitreous humor) are located within the eyeball, making them distinct from extracellular fluids.

4. The physician has ordered a peripheral IV to be inserted before the patient goes for computed tomography. What should the nurse do when selecting a site on the hand or arm for insertion of an IV catheter?

• A. Choose a site with minimal hair if available.
• B. Consider potential effects on the patient's mobility when selecting a site.
• C. Instruct the patient to hold his arm in a dependent position before insertion.
• D. Remove the tourniquet after 2 minutes.

Correct answer: B

Rationale: When selecting a site for IV insertion on the hand or arm, it is important to consider the potential effects on the patient's mobility. The chosen site should not interfere with the patient's movement. Instructing the patient to hold his arm in a dependent position helps increase blood flow, aiding in vein visualization and insertion. It is advisable to choose a site with minimal hair if possible for better adhesion of the dressing. Removing the tourniquet after 2 minutes is recommended to prevent complications like hemoconcentration and potential vein damage. Therefore, option B is the correct choice as it aligns with best practices for IV insertion.

5. After administering 40 mEq of potassium chloride, a nurse evaluates the clients response. Which manifestations indicate that treatment is improving the clients hypokalemia? (Select all tha do not t apply.)

• A. Strong productive cough
• B. Active bowel sounds
• C. U waves present on the electrocardiogram (ECG)
• D.

Correct answer: C

Rationale:

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