Nursing Elites

1. A nurse is caring for a client who is having a subclavian central venous catheter inserted. The client begins to report chest pain and difficulty breathing. After administering oxygen, which action should the nurse take next?

• A. Administer a sublingual nitroglycerin tablet
• B. Prepare to assist with chest tube insertion.
• C. . Place a sterile dressing over the IV site
• D. Re-position the client into the Trendelenburg position.

Correct answer: B

Rationale:

2. The nurse is admitting a patient with a suspected fluid imbalance. The most sensitive indicator of body fluid balance is:

• A. Daily weight
• B. Serum sodium levels
• C. Measured intake and output
• D. Blood pressure

Correct answer: A

Rationale: Daily weight is the most sensitive indicator of body fluid balance because it can show trends over time, helping in assessing the effectiveness of interventions and medications. While serum sodium levels provide objective data on electrolyte balance, they may not accurately reflect fluid balance, especially if a patient is dehydrated. Measured intake and output are crucial for assessing fluid balance, but it can be challenging to match the two due to various ways fluid is lost from the body. Blood pressure and other vital signs may not always be reliable indicators of fluid balance as they can be influenced by other factors beyond fluid status.

3. The nurse is assessing the patient for the presence of a Chvostek's sign. What electrolyte imbalance does a positive Chvostek's sign indicate?

• A. Hypermagnesemia
• B. Hypomagnesemia
• C. Hypocalcemia
• D. Hyperkalemia

Correct answer: C

Rationale: Chvostek's sign is characterized by a brief contraction of the upper lip, nose, or side of the face and is indicative of hypocalcemia, making choice C the correct answer. Hypomagnesemia (choice B) is associated with Trousseau's sign, not Chvostek's sign. Hypermagnesemia (choice A) is not related to Chvostek's sign. Hyperkalemia (choice D) is not typically associated with Chvostek's sign; instead, it may present with muscle weakness and cardiac arrhythmias.

4. When considering overhydration:

• A. occurs less often than dehydration.
• B. can strain the kidneys.
• C. can be caused by giving intravenous fluids too rapidly.
• D. less common than dehydration.

Correct answer: C

Rationale: The correct answer is C. Overhydration can occur when intravenous fluids are administered too quickly, overwhelming the body's ability to excrete the excess fluid. Choices A, B, and D are incorrect. Choice A is incorrect because overhydration is less common than dehydration. Choice B is incorrect because while overhydration can strain the kidneys, it is not due to the burden being too heavy. Choice D is incorrect because dehydration is more common than overhydration.

5. 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.

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