Nursing Elites

1. When administering IV fluids to a dehydrated patient, what is the nurse's priority assessment?

• A. Monitor the patient's electrolyte levels.
• B. Assess the patient's blood pressure regularly.
• C. Monitor the patient's heart rate every 4 hours.
• D. Check the patient's urine output hourly.

Correct answer: B

Rationale: The correct answer is to assess the patient's blood pressure regularly. Monitoring blood pressure is crucial when administering IV fluids to a dehydrated patient as it helps in evaluating the patient's fluid status. Changes in blood pressure can indicate the effectiveness of the fluid therapy, the patient's response to treatment, and the possibility of complications such as fluid overload or hypovolemia. Monitoring electrolyte levels (Choice A) is essential but not the priority when assessing a dehydrated patient receiving IV fluids. Heart rate (Choice C) should be monitored more frequently than every 4 hours in such a situation. Checking urine output (Choice D) is important but not as critical as assessing blood pressure in this scenario.

2. A client who has been having frequent tonic-clonic seizures is being admitted by a nurse. Which of the following actions should the nurse add to the client's plan of care?

• A. Apply restraints
• B. Use soft wristbands
• C. Wrap blankets around side rails
• D. Administer sedatives

Correct answer: C

Rationale: The correct action the nurse should add to the client's plan of care is to wrap blankets around side rails. This helps prevent injury during seizures by providing a cushioned surface against the hard rails. Applying restraints (Choice A) is not recommended as it can cause harm during a seizure. Using soft wristbands (Choice B) may not provide adequate protection against injury. Administering sedatives (Choice D) is not typically indicated for managing tonic-clonic seizures as they require specific anti-seizure medications.

3. A healthcare provider prescribes a higher-than-usual dose of medication. What is the nurse's first action?

• A. Administer the medication and monitor closely.
• B. Hold the medication and consult the pharmacist.
• C. Ask another nurse to verify the dose.
• D. Call the provider for clarification.

Correct answer: D

Rationale: The correct answer is to call the provider for clarification. When faced with a higher-than-usual dose of medication, the nurse's first action should be to contact the prescribing healthcare provider to confirm the dosage. Administering the medication without clarifying the dose with the provider can pose serious risks to the patient's safety. Holding the medication and consulting the pharmacist may be appropriate after contacting the provider for clarification. Asking another nurse to verify the dose is not the most appropriate action when dealing with an unusual prescription; direct communication with the provider is essential in such situations.

4. A patient is at risk for impaired skin integrity. What is the priority intervention for the nurse?

• A. Turn and reposition the patient every 2 hours.
• B. Apply a moisture barrier to the patient's skin.
• C. Massage the patient's skin to promote circulation.
• D. Apply a heating pad to the patient's skin to increase blood flow.

Correct answer: A

Rationale: The correct answer is to turn and reposition the patient every 2 hours. This intervention is crucial in preventing pressure ulcers and maintaining skin integrity by relieving pressure on bony prominences. Applying a moisture barrier (Choice B) is important for moisture-associated skin damage but is not the priority in this case. Massaging the patient's skin (Choice C) can potentially cause friction and shear, increasing the risk of skin breakdown. Applying a heating pad (Choice D) can lead to burns or thermal injuries, exacerbating skin integrity issues.

5. A healthcare provider is planning care for a client who has fluid overload. Which of the following actions should the provider plan to take first?

• A. Assess for edema
• B. Evaluate electrolytes
• C. Restrict fluid intake
• D. Administer diuretics

Correct answer: B

Rationale: Evaluating electrolytes is crucial when addressing fluid overload as it helps determine the severity of the imbalance and guides treatment. Assessing for edema (Choice A) is important but not the priority over evaluating electrolytes. Restricting fluid intake (Choice C) and administering diuretics (Choice D) are interventions that may be necessary but should be based on the electrolyte evaluation to ensure safe and effective care.

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