Nursing Elites

1. A client with a cast complains of numbness and tingling in the affected limb. What should the nurse do first?

• A. Check for tightness of the cast
• B. Elevate the limb
• C. Apply ice to the area
• D. Notify the physician

Correct answer: A

Rationale: The correct first action for a client with a cast experiencing numbness and tingling in the affected limb is to check for tightness of the cast. Numbness and tingling can indicate compromised circulation, and a tight cast may be causing this. Checking the cast for tightness is essential to ensure it is not impeding circulation. Elevating the limb, applying ice, or notifying the physician can be subsequent actions depending on the assessment findings after checking the cast. Elevating the limb might help improve circulation, applying ice is not indicated for numbness and tingling, and notifying the physician can be done if the issue persists after addressing the immediate concern of cast tightness.

2. The nurse is monitoring a client with an IV infusion in the left antecubital fossa. The site is warm, red, and without swelling. What conclusion should the nurse draw from these findings?

• A. The IV fluids are infusing into the subcutaneous tissues
• B. The infusion pump is functioning properly
• C. The insertion date should be verified and the IV discontinued
• D. The site is inflamed and should be reported

Correct answer: B

Rationale: The correct answer is B. Warmth and redness at the IV site without swelling indicate a localized reaction, which is common and does not necessarily indicate infiltration of IV fluids into the subcutaneous tissues. The absence of swelling suggests that the IV is correctly placed. Therefore, the nurse should conclude that the infusion pump is functioning properly. Choice A is incorrect as warmth and redness alone do not indicate subcutaneous infiltration. Choice C is incorrect as discontinuing the IV solely based on warmth and redness without swelling is not necessary. Choice D is incorrect as the absence of swelling signifies a localized reaction rather than inflammation requiring immediate reporting.

3. The client has chronic renal failure. What dietary modification is most important for this client?

• A. Increase protein intake
• B. Limit potassium-rich foods
• C. Increase sodium intake
• D. Encourage dairy products

Correct answer: B

Rationale: Limiting potassium-rich foods is crucial in chronic renal failure to prevent hyperkalemia, which can lead to cardiac complications. Excessive protein intake can increase the workload on the kidneys and may result in the accumulation of uremic toxins. Increasing sodium intake is generally discouraged in chronic renal failure due to its association with hypertension and fluid retention. Encouraging dairy products may not be suitable for all clients with chronic renal failure, as they are a significant source of phosphorus, which needs to be limited in renal failure to prevent mineral imbalances.

4. A client with a history of seizure disorder who is receiving phenytoin (Dilantin) is being discharged. Which instruction should the nurse provide?

• A. Take the medication at bedtime.
• B. Monitor drug levels regularly.
• C. Avoid alcohol while taking this medication.
• D. Take the medication at the same time every day.

Correct answer: B

Rationale: The correct answer is to instruct the client to monitor drug levels regularly. This is crucial for phenytoin (Dilantin) to ensure that the medication levels are within the therapeutic range and to prevent toxicity. Choice A, taking the medication at bedtime, is not specifically required for phenytoin administration. Choice C, avoiding alcohol, is generally a good practice with medications but is not as critical as monitoring drug levels for phenytoin. Choice D, taking the medication at the same time every day, is important for consistency but does not address the specific monitoring needs of phenytoin.

5. The nurse is assessing a client with chronic liver disease. Which lab value is most concerning?

• A. Elevated AST and ALT levels
• B. Decreased albumin level
• C. Elevated bilirubin level
• D. Prolonged PT/INR

Correct answer: D

Rationale: In a client with chronic liver disease, a prolonged PT/INR is the most concerning lab value. This finding indicates impaired liver function affecting the synthesis of clotting factors, leading to an increased risk of bleeding. Elevated AST and ALT levels (Choice A) indicate liver cell damage but do not directly correlate with the risk of bleeding. A decreased albumin level (Choice B) is common in liver disease but is not the most concerning in terms of bleeding risk. Elevated bilirubin levels (Choice C) are seen in liver disease but do not directly reflect the risk of bleeding as PT/INR values do.

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