Nursing Elites

1. A client is admitted with a diagnosis of fluid volume deficit. Which clinical finding would the nurse expect?

• A. Bounding pulse
• B. Bradycardia
• C. Oliguria
• D. Dry mucous membranes

Correct answer: D

Rationale: Dry mucous membranes (D) are a common clinical finding indicating fluid volume deficit. In dehydration, there is insufficient fluid in the body, leading to dry mucous membranes due to decreased saliva production. Bounding pulse (A) is associated with fluid volume excess, not deficit. Bradycardia (B) and oliguria (C) are not typical clinical findings of fluid volume deficit but may be seen in fluid volume excess or other conditions.

2. When performing sterile wound care in the acute care setting, the nurse obtains a bottle of normal saline from the bedside table that is labeled 'opened' and dated 48 hours prior to the current date. Which is the best action for the nurse to take?

• A. Use the normal saline solution once more and then discard.
• B. Obtain a new sterile syringe to draw up the labeled saline solution.
• C. Use the saline solution and then relabel the bottle with the current date.
• D. Discard the saline solution and obtain a new unopened bottle.

Correct answer: D

Rationale: When performing sterile wound care, it is essential to use only newly opened and unexpired solutions to maintain sterility and prevent infections. The normal saline solution obtained by the nurse is labeled 'opened' and dated 48 hours prior to the current date, making it no longer considered sterile. The best action for the nurse to take in this situation is to discard the saline solution and obtain a new unopened bottle to ensure the safety and effectiveness of wound care. Choices A, B, and C are incorrect because reusing an already opened and outdated solution or attempting to relabel it with a current date can compromise patient safety and increase the risk of infection.

3. The nurse is administering the 0900 medications to a client who was admitted during the night. Which client statement indicates that the nurse should further assess the medication order?

• A. At home I take my pills at 8:00 am.
• B. It costs a lot of money to buy all of these pills.
• C. I get so tired of taking pills every day.
• D. This is a new pill I have never taken before.

Correct answer: D

Rationale: The client's statement that 'This is a new pill I have never taken before' indicates the need for further assessment by the nurse to ensure the medication is correct and safe. Choices A, B, and C do not raise immediate concerns about the medication order; therefore, they are incorrect. Choice A simply provides information about the client's usual medication schedule, choice B is related to the cost of the pills, and choice C expresses fatigue from taking pills, but none of these statements suggest a potential issue with the new medication.

4. When a student nurse is caught taking a copy of a client's medication administration record to help a friend prepare for the next day's clinical, what should the nurse respond first?

• A. Ask the nursing supervisor to meet with the student.
• B. Notify the student's clinical instructor of the situation.
• C. Ask the student if permission was obtained from the client.
• D. Explain that the records are hospital property and may not be removed.

Correct answer: D

Rationale: The correct response when a student nurse is caught taking a copy of a client's medication administration record is to explain that the records are hospital property and cannot be removed. It is essential to educate the student about the confidentiality and security of patient information, emphasizing that even with the client's consent, such actions are unacceptable. Option A is not the immediate action needed, as addressing the student directly should come first. Option B involves notifying another party before addressing the student directly. Option C is incorrect because even if the client gave permission, patient records are confidential and cannot be shared without authorization.

5. The healthcare provider selects the best site for insertion of an IV catheter in the client's right arm. Which documentation should the healthcare provider use to identify placement of the IV access?

• A. Left brachial vein
• B. Right cephalic vein
• C. Dorsal side of the right wrist
• D. Right upper extremity

Correct answer: B

Rationale: The correct answer is B: Right cephalic vein. The cephalic vein is a large, superficial vein located on the radial side of the forearm, making it the preferred site for IV access. It is often the best choice for insertion of an IV catheter due to its accessibility and low risk of complications, such as infiltration. Documenting the use of the right cephalic vein for IV access is crucial for accurate and safe patient care. Choices A, C, and D are incorrect because the left brachial vein, the dorsal side of the right wrist, and the right upper extremity are not typically preferred sites for IV catheter insertion and may not provide optimal access or outcomes.

Similar Questions