Nursing Elites

1. A medical-surgical nurse is concerned about the incidence of complications related to IV therapy, including bloodstream infection. Which intervention should the nurse suggest to the management team to make the biggest impact on decreasing complications

• A. Initiate a dedicated team to insert access devices
• B. . Require additional education for all nurses.
• C. Limit the use of peripheral venous access devices.
• D. Perform quality control testing on skin preparation products.

Correct answer: A

Rationale:

2. 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.

3. You are making initial shift assessments on your patients. While assessing one patients peripheral IV site, you note edema around the insertion site. How should you document this complication related to IV therapy?

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

Correct answer: C

Rationale:

4. Extracellular fluid includes:

• A. plasma and intracellular fluid.
• B. interstitial and intracellular fluids.
• C. plasma and interstitial fluid.
• D. plasma, interstitial fluid, and intracellular fluid.

Correct answer: C

Rationale: The correct answer is C: 'plasma and interstitial fluid.' Extracellular fluid consists of all body fluids outside the cells, primarily including plasma (the liquid component of blood) and interstitial fluid (the fluid between cells). Choices A, B, and D are incorrect because intracellular fluid is located within the cells, not in the extracellular fluid compartment.

5. A patient with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acid-base imbalance?

• A. Respiratory acidosis
• B. Respiratory alkalosis
• C. Increased PaCO2
• D. CNS disturbances

Correct answer: B

Rationale: The correct answer is B: Respiratory alkalosis. Hyperventilation, which can be caused by extreme anxiety, is the most common cause of acute respiratory alkalosis. This leads to a decrease in PaCO2 levels. Respiratory acidosis, choice A, occurs in conditions like hypoventilation, leading to an increase in PaCO2 levels. Choice C, Increased PaCO2, is not the correct term for an acid-base imbalance related to hyperventilation. Choice D, CNS disturbances, is not directly related to the acid-base imbalance caused by hyperventilation.

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