Nursing Elites

1. A nurse is preparing to administer an IV bolus of 0.9% sodium chloride to a client who is dehydrated. Which of the following actions should the nurse take?

• A. Administer the solution slowly over 24 hours
• B. Assess the client's lung sounds before administration
• C. Change the IV tubing every 12 hours
• D. Flush the IV line with 2 mL of heparin every 4 hours

Correct answer: B

Rationale: The correct action for the nurse to take is to assess the client's lung sounds before administering IV fluids. This is crucial to identify any signs of fluid overload, such as crackles or wheezes. Administering the solution slowly over 24 hours (choice A) is not appropriate for an IV bolus, which is a rapid infusion. Changing the IV tubing every 12 hours (choice C) is a standard practice for preventing infection but is not directly related to administering an IV bolus. Flushing the IV line with heparin every 4 hours (choice D) is a maintenance practice to prevent clot formation in the line, not specifically related to administering an IV bolus.

2. A nurse is caring for a client who is 32 weeks pregnant and has cardiac disease. Which of the following positions should the nurse place the client in to promote optimal cardiac output?

• A. Semi-Fowler's
• B. Supine with head elevated
• C. Left lateral
• D. Right lateral

Correct answer: C

Rationale: The correct answer is C: Left lateral. Placing the client in the left lateral position helps promote optimal cardiac output during pregnancy by avoiding pressure on the vena cava. This position improves venous return to the heart and subsequently cardiac output. Option A, Semi-Fowler's position, may not be the best choice for a client with cardiac disease as it does not alleviate pressure on the vena cava. Option B, supine with head elevated, can also compress the vena cava, reducing cardiac output. Option D, right lateral position, does not provide the same benefits as the left lateral position for cardiac output during pregnancy.

3. A nurse is planning care for a client who has chronic obstructive pulmonary disease (COPD). Which of the following actions should the nurse take?

• A. Encourage the client to increase physical activity.
• B. Place the client in the Trendelenburg position.
• C. Limit the client's fluid intake to prevent fluid overload.
• D. Administer high-flow oxygen via mask.

Correct answer: A

Rationale: The correct action for the nurse to take when caring for a client with COPD is to encourage the client to increase physical activity. Increased physical activity helps manage COPD symptoms by improving lung function and preventing deconditioning. Placing the client in the Trendelenburg position is not recommended for COPD as it can worsen breathing difficulties. Limiting fluid intake to prevent fluid overload is not typically necessary in COPD unless the client has comorbid conditions that require fluid restriction. Administering high-flow oxygen via mask may be necessary for COPD clients with severe hypoxemia, but it is not the initial action for planning care.

4. Which diagnostic test is used to confirm tuberculosis (TB) infection?

• A. Chest X-ray
• B. Sputum culture
• C. Skin test (Mantoux)
• D. MRI

Correct answer: C

Rationale: The Mantoux skin test, also known as the Tuberculin Skin Test (TST), is used to confirm tuberculosis (TB) infection. This test involves injecting a small amount of tuberculin protein derivative under the top layer of the skin and then evaluating the immune system's response to the protein. A positive reaction indicates exposure to the TB bacteria. Chest X-rays are used to detect abnormalities in the lungs caused by TB but are not confirmatory. Sputum culture is used to identify the presence of TB bacteria in the sputum. MRIs are not typically used as a primary diagnostic tool for TB.

5. A nurse is assessing a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect?

• A. Increased appetite
• B. Dry mucous membranes
• C. Hypotension
• D. Hyperreflexia

Correct answer: C

Rationale: A sodium level of 125 mEq/L indicates hyponatremia, which can lead to hypotension. Hyponatremia is associated with signs such as confusion and weakness, rather than increased appetite, dry mucous membranes, or hyperreflexia. Therefore, the nurse should expect hypotension as a finding in a client with a sodium level of 125 mEq/L.

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