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. A nurse is assessing a client who has acute pancreatitis and is at risk for an acid-base imbalance. For which manifestation of this acid-base imbalance should the nurse assess?

• A. Agitation
• B. Kussmaul respirations
• C. Seizures
• D. Positive Chvosteks sign

Correct answer: B

Rationale:

3. The physician has ordered a peripheral IV to be inserted before the patient goes for computed tomography. What should the nurse do when selecting a site on the hand or arm for insertion of an IV catheter?

• A. Choose a site with minimal hair if available.
• B. Consider potential effects on the patient's mobility when selecting a site.
• C. Instruct the patient to hold his arm in a dependent position before insertion.
• D. Remove the tourniquet after 2 minutes.

Correct answer: B

Rationale: When selecting a site for IV insertion on the hand or arm, it is important to consider the potential effects on the patient's mobility. The chosen site should not interfere with the patient's movement. Instructing the patient to hold his arm in a dependent position helps increase blood flow, aiding in vein visualization and insertion. It is advisable to choose a site with minimal hair if possible for better adhesion of the dressing. Removing the tourniquet after 2 minutes is recommended to prevent complications like hemoconcentration and potential vein damage. Therefore, option B is the correct choice as it aligns with best practices for IV insertion.

4. A nurse teaches a client who is being discharged home with a peripherally inserted central catheter (PICC). Which statement should the nurse include in this clients teaching?

• A. avoid carrying your grandchild with the arm that has the central catheter.
• B. Be sure to place the arm with the central catheter in a sling during the day
• C. Flush the peripherally inserted central catheter line with normal saline daily.
• D. You can use the arm with the central catheter for most activities of daily living.

Correct answer: A

Rationale:

5. A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical manifestations are correctly paired with the contributing electrolyte imbalance? (Select all that do not apply.)

• A. Hypokalemia Flaccid paralysis with respiratory depression
• B. Hyperphosphatemia Paresthesia with sensations of tingling and numbness
• C. . Hyponatremia Decreased level of consciousness
• D.

Correct answer: B

Rationale:

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