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 with osteoporosis is being taught by a nurse about dietary changes. Which of the following food choices should the nurse recommend to promote bone health?

• A. Leafy green vegetables
• B. Red meat
• C. Fortified orange juice
• D. Whole grains

Correct answer: C

Rationale: The correct answer is C: Fortified orange juice. Fortified orange juice is often supplemented with calcium and vitamin D, both of which are essential for bone health and the prevention of osteoporosis. Leafy green vegetables (choice A) are good for overall health but may not provide sufficient calcium for bone health. Red meat (choice B) is a source of protein but is not a primary source of calcium. Whole grains (choice D) are beneficial for fiber intake but do not contain significant amounts of calcium or vitamin D necessary for bone health.

3. A nurse is caring for a client who has schizophrenia. Which of the following assessment findings should the nurse expect?

• A. Decreased level of consciousness
• B. Inability to identify common objects
• C. Poor problem-solving ability
• D. Preoccupation with somatic disturbances

Correct answer: C

Rationale: In clients with schizophrenia, poor problem-solving ability is a common assessment finding due to impaired cognitive function associated with the disorder. This impairment can manifest as difficulties in decision-making and problem-solving. Choice A, decreased level of consciousness, is not a typical finding in schizophrenia. Choice B, inability to identify common objects, is more indicative of conditions like dementia rather than schizophrenia. Choice D, preoccupation with somatic disturbances, is more characteristic of somatic symptom disorder rather than schizophrenia.

4. A healthcare professional is preparing to administer an IM injection to a 4-month-old infant. Which of the following injection sites should the healthcare professional use?

• A. Ventrogluteal
• B. Deltoid
• C. Dorsogluteal
• D. Vastus lateralis

Correct answer: D

Rationale: The vastus lateralis is the preferred site for IM injections in infants under 1 year of age because it is well developed and easily accessible compared to other muscle groups. The ventrogluteal and deltoid sites are not typically used for infants due to muscle development and size. The dorsogluteal site is not recommended for infants or young children due to its proximity to major nerves and blood vessels.

5. A nurse in an outpatient facility is assessing a client who is prescribed furosemide 40 mg daily, but the client reports she has been taking extra doses to promote weight loss. Which of the following findings indicates she is dehydrated?

• A. Urine specific gravity of 1.020
• B. Urine specific gravity of 1.035
• C. Decreased skin turgor
• D. Decreased heart rate

Correct answer: B

Rationale: The correct answer is B. A urine specific gravity greater than 1.030 is indicative of dehydration as it reflects concentrated urine. Choice A is incorrect as a specific gravity of 1.020 is within the normal range. Choice C, decreased skin turgor, can be a sign of dehydration but is not as specific as urine specific gravity. Choice D, decreased heart rate, is not typically a direct indicator of dehydration.

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