Nursing Elites

1. A nurse is caring for a client who has dehydration. The client has a peripheral IV and has a prescription for an infusion of 0.9% sodium chloride 1,000 mL with 40 mEq potassium chloride to infuse over 1 hr. Which of the following actions should the nurse take first?

• A. Teach the client to report findings of IV extravasation
• B. Evaluate the patency of the IV
• C. Consult with the pharmacist about the prescription
• D. Verify the prescription with the provider

Correct answer: D

Rationale: The priority action is to verify the prescription with the provider. Verifying the prescription ensures patient safety by preventing fluid volume overload and dysrhythmias, which can result from infusing potassium too rapidly. Teaching the client about IV extravasation, evaluating IV patency, and consulting with the pharmacist are important but should come after verifying the prescription to ensure the ordered treatment is appropriate and safe for the client's condition.

2. A nurse is reviewing the laboratory results for a client who is at 29 weeks of gestation. Which of the following results should the nurse report to the provider?

• A. WBC count 11,000/mm³
• B. Hgb 11.2 g/dL
• C. Hct 34%
• D. Platelets 140,000/mm³

Correct answer: D

Rationale: A platelet count of 140,000/mm³ is at the lower end of the normal range but can be concerning in pregnancy, especially if there are signs of thrombocytopenia or bleeding. Thrombocytopenia in pregnancy can lead to complications such as bleeding during childbirth or excessive bleeding postpartum. The other laboratory values mentioned are within normal ranges for pregnancy and do not typically raise immediate concerns. High WBC counts can be a normal response to pregnancy, hemoglobin levels around 11.2 g/dL and hematocrit levels around 34% are also considered normal in the third trimester.

3. A nurse is assessing a client who has diabetic ketoacidosis (DKA). Which of the following laboratory findings should the nurse expect?

• A. Blood glucose 120 mg/dL
• B. pH 7.32
• C. HCO3 25 mEq/L
• D. PaCO2 48 mm Hg

Correct answer: B

Rationale: The correct answer is B. A pH of 7.32 indicates metabolic acidosis, which is a hallmark of diabetic ketoacidosis (DKA). In DKA, blood glucose levels are typically elevated, bicarbonate levels are often low, and there is a compensatory respiratory response leading to a decrease in PaCO2. Option A is incorrect because a blood glucose level of 120 mg/dL is within the normal range and not indicative of DKA. Option C is incorrect because an HCO3 level of 25 mEq/L is not typically seen in DKA where bicarbonate levels are usually lower. Option D is incorrect because a PaCO2 of 48 mm Hg would not be expected in DKA; it would typically be lower due to compensatory respiratory alkalosis.

4. A nurse is planning care to prevent complications in a client with immobility. Which of the following interventions should the nurse include?

• A. Massage lower extremities daily to prevent DVT
• B. Remove anti-embolism stockings for 3 hours each day
• C. Limit intake of foods high in calcium to prevent renal calculi
• D. Encourage the client to lie supine to prevent constipation

Correct answer: B

Rationale: The correct answer is B because removing anti-embolism stockings for short periods prevents skin breakdown while ensuring that the stockings remain effective in promoting circulation. Choice A is incorrect because massaging lower extremities daily does not prevent DVT; instead, it may dislodge a clot. Choice C is incorrect as limiting intake of foods high in calcium does not prevent renal calculi; rather, it may help reduce the risk of kidney stones. Choice D is incorrect because encouraging the client to lie supine does not prevent constipation; instead, encouraging mobility and adequate fluid intake can help prevent constipation in immobile clients.

5. A nurse is planning care for a patient who follows the Mormon belief system. What modifications should the nurse include to meet Mormon dietary practices?

• A. Offer only vegetarian meal options.
• B. Offer non-caffeinated beverage options.
• C. Offer kosher meals.
• D. Limit meat to only fish and poultry.

Correct answer: B

Rationale: The correct answer is B: Offer non-caffeinated beverage options. Mormons avoid caffeinated beverages, so providing non-caffeinated options aligns with their religious practices. Choice A is incorrect because offering only vegetarian meal options is not a specific requirement of the Mormon dietary practices. Choice C is incorrect as kosher meals are associated with Jewish dietary laws, not specific to the Mormon belief system. Choice D is incorrect as limiting meat to only fish and poultry is not a specific dietary requirement for Mormons.

Similar Questions