Nursing Elites

1. A nurse is caring for a client who reports burning around the peripheral IV site. Which finding should the nurse identify as a manifestation of infiltration?

• A. Redness at the site
• B. Warmth around the site
• C. Edema
• D. Pain at the site

Correct answer: C

Rationale: Edema at the IV site indicates that IV solution has leaked into the extravascular tissue, which is a sign of infiltration. Redness, warmth, and pain at the site are more indicative of phlebitis, not infiltration. Phlebitis is characterized by redness, warmth, and pain along the vein where the IV is placed, while infiltration involves the leaking of IV fluids into the surrounding tissue.

2. A client is being educated about the use of spironolactone. Which of the following should be included in the teaching?

• A. Avoid potassium-rich foods
• B. Take the medication with food
• C. Monitor for signs of toxicity
• D. Discontinue the medication if potassium levels rise

Correct answer: A

Rationale: The correct answer is A: Avoid potassium-rich foods. Spironolactone can lead to hyperkalemia, a condition characterized by high levels of potassium in the blood. To prevent this complication, clients taking spironolactone should avoid potassium-rich foods. Choice B is incorrect because spironolactone can be taken with or without food. Choice C is not directly related to spironolactone use, as toxicity monitoring is not a specific concern with this medication. Choice D is incorrect because discontinuing the medication solely based on elevated potassium levels may not be necessary; instead, dosage adjustments or potassium restriction are often more appropriate.

3. A nurse is caring for a patient whose family member requests to view the patient’s medical record. What response should the nurse make?

• A. “The patient should provide permission to share the records with you.”
• B. “You can view the records if the provider approves it.”
• C. “I will allow you to see the chart if the patient is unable to give consent.”
• D. “You need to fill out a request form.”

Correct answer: A

Rationale: In this scenario, the nurse should respond by indicating that the patient needs to provide permission to share their medical records with the family member. Patient confidentiality is a fundamental principle in healthcare, and sharing medical records without the patient's consent is a violation of privacy. Choice B is incorrect because the provider's approval alone is not sufficient to share medical records, as patient consent is crucial. Choice C is incorrect because viewing the patient's chart without the patient's consent is not appropriate. Choice D is incorrect as filling out a request form does not address the issue of patient consent, which is essential for sharing medical information.

4. A nurse is assessing a pregnant client at 32 weeks gestation and notes that the client has gained 5 pounds in one week. Which of the following conditions should the nurse suspect?

• A. Preeclampsia
• B. Gestational diabetes
• C. Anemia
• D. Placenta previa

Correct answer: A

Rationale: The correct answer is A: Preeclampsia. Rapid weight gain, especially in the third trimester, can be a sign of preeclampsia, a condition characterized by hypertension, edema, and proteinuria. This requires immediate medical attention. Choice B, Gestational diabetes, is incorrect because rapid weight gain is not a typical symptom of gestational diabetes. Choice C, Anemia, is incorrect as weight gain is not a common sign of anemia in pregnancy. Choice D, Placenta previa, is also incorrect because weight gain is not a typical symptom of this condition, which involves the placenta partially or completely covering the cervix.

5. A nurse is preparing to administer a dose of losartan. Which of the following should the nurse assess first?

• A. Blood pressure
• B. Heart rate
• C. Serum potassium
• D. Liver function

Correct answer: A

Rationale: The correct answer is to assess blood pressure first. Losartan is an angiotensin receptor blocker used to lower blood pressure. Assessing the patient's blood pressure before administering losartan is crucial to ensure it is not already too low, which could lead to hypotension. Assessing heart rate (choice B) is important but not the priority when administering losartan. Serum potassium levels (choice C) and liver function (choice D) are also important assessments, but they are not the primary concern before administering losartan.

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