Nursing Elites

1. A newly admitted patient is diagnosed with hyponatremia. When making room assignments, the charge nurse should take which action?

• A. Assign the patient to a room near the nurse’s station.
• B. Place the patient in a room nearest to the water fountain.
• C. Place the patient on telemetry to monitor for peaked T waves.
• D. Assign the patient to a semi-private room and place an order for a low-salt diet.

Correct answer: A

Rationale: The correct answer is A. The patient should be placed near the nurse’s station if confused to allow close monitoring by the staff. To help improve serum sodium levels, water intake is restricted, so a patient with hyponatremia should not be placed near a water fountain. Peaked T waves are a sign of hyperkalemia, not hyponatremia, so telemetry for this purpose is unnecessary. Placing a confused patient in a semi-private room could be disruptive to the other patient. Additionally, the patient needs sodium replacement, not a low-salt diet.

2. Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room?

• A. Tie the knot with a double turn or square knot
• B. Ensure that the restraints are snug against the client's wrists
• C. Ensure that the knot can be quickly released
• D. Move the ties so the restraints are secured to the side rails

Correct answer: C

Rationale: The priority is to ensure that the knot can be quickly released to allow for quick intervention if necessary. Tying the knot with a double turn or square knot (Choice A) may make it more difficult to release quickly in an emergency. Ensuring that the restraints are snug against the client's wrists (Choice B) may compromise circulation and cause discomfort. Moving the ties to secure the restraints to the side rails (Choice D) is not the appropriate action as it can limit the client's movement and access to care.

3. The nurse observes an unlicensed assistive personnel (UAP) who is providing a total bed bath for a confused and lethargic client. The UAP is soaking the client's foot in a basin of warm water placed on the bed. What action should the nurse take?

• A. Remove the basin of water from the client's bed immediately
• B. Remind the UAP to dry between the client's toes completely
• C. Advise the UAP that this procedure is damaging to the skin
• D. Add skin cream to the basin of water while the foot is soaking

Correct answer: B

Rationale: Choice (B) is the correct action for the nurse to take in this situation. Ensuring that the UAP dries between the client's toes completely is crucial to prevent skin breakdown due to excessive moisture. While keeping the client's feet clean is important, maintaining dryness is paramount for skin integrity. Choices (A), (C), and (D) are incorrect: (A) removing the basin of water immediately may disrupt the care process without addressing the root issue, (C) advising the UAP that the procedure is damaging to the skin is not as immediate or specific to the observed problem, and (D) adding skin cream to the water may not address the need for drying the client's toes thoroughly.

4. IV potassium chloride (KCl) 60 mEq is prescribed for the treatment of a patient with severe hypokalemia. Which action should the nurse take?

• A. Administer the KCl as a rapid IV bolus.
• B. Infuse the KCl at a rate of 10 mEq/hour.
• C. Only give the KCl through a central venous line.
• D. Discontinue cardiac monitoring during the infusion.

Correct answer: B

Rationale: The correct action for the nurse to take is to infuse the KCl at a rate of 10 mEq/hour. Rapid IV infusion of KCl can lead to cardiac arrest due to its potential for causing hyperkalemia. While KCl can be administered through peripheral veins, central venous lines are not necessary unless specified. It is crucial to continue cardiac monitoring during potassium infusion to promptly identify and manage any potential dysrhythmias that may occur.

5. The nurse is caring for a patient who has a central venous access device (CVAD). Which action by the nurse is appropriate?

• A. Avoid using friction when cleaning around the CVAD insertion site.
• B. Use the push-pause method to flush the CVAD after giving medications.
• C. Obtain an order from the healthcare provider to change the CVAD dressing.
• D. Position the patient’s face away from the CVAD during injection cap changes.

Correct answer: B

Rationale: The correct answer is B because using the push-pause method to flush the CVAD after giving medications helps remove debris from the CVAD lumen and decreases the risk for clotting. Choice A is incorrect because friction should be used when cleaning the CVAD insertion site to decrease infection risk. Choice C is incorrect because obtaining an order from the healthcare provider to change the CVAD dressing is not necessary; the dressing should be changed when damp, loose, or visibly soiled. Choice D is incorrect because the patient should face away from the CVAD during cap changes to minimize the risk of contamination.

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