Nursing Elites

1. A nurse assesses a client who has a radial artery catheter. Which assessment should the nurse complete first?

• A. . Amount of pressure in fluid container
• B. Date of catheter tubing change
• C. Percent of heparin in infusion container
• D. . Presence of an ulnar pulse

Correct answer: D

Rationale:

2. An increase in capillary blood pressure would tend to:

• A. increase interstitial fluid volume.
• B. increase plasma volume.
• C. decrease interstitial fluid volume.
• D. increase plasma volume and decrease interstitial fluid volume.

Correct answer: A

Rationale: An increase in capillary blood pressure leads to a higher force pushing fluid out of the capillaries into the interstitial space, thereby increasing interstitial fluid volume. Choice B is incorrect because capillary blood pressure affects the movement of fluid into the interstitial space, not into the plasma. Choice C is incorrect as an increase in capillary blood pressure would not decrease interstitial fluid volume. Choice D is incorrect as it combines contradictory effects when capillary blood pressure increases.

3. 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.

4. A nurse evaluates a clients arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg, PaCO2 55 mm Hg, and HCO3 22 mEq/L. Which intervention should the nurse implement first?

• A. Assess the airway.
• B. Administer prescribed bronchodilators.
• C. Provide oxygen.
• D. Administer prescribed mucolytics

Correct answer: A

Rationale:

5. A nurse is assessing a client with hypokalemia and notes that the client's handgrip strength has diminished since the previous assessment 1 hour ago. Which action should the nurse take first?

• A. Assess the client's respiratory rate, rhythm, and depth.
• B. Measure the client's pulse and blood pressure.
• C. Document findings and monitor the client.
• D. Call the healthcare provider.

Correct answer: A

Rationale: In a client with hypokalemia experiencing diminished handgrip strength, the priority action for the nurse is to assess the client's respiratory rate, rhythm, and depth. Hypokalemia can lead to muscle weakness, including respiratory muscles, potentially causing respiratory distress. Assessing the respiratory status is crucial to determine if immediate interventions are needed to maintain adequate oxygenation. Measuring the client's pulse and blood pressure (Choice B) is important but should come after assessing the respiratory status. Simply documenting findings and monitoring the client (Choice C) may delay necessary interventions. Calling the healthcare provider (Choice D) is not the first action indicated in this situation; assessing the client's respiratory status takes precedence.

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