Nursing Elites

1. A healthcare professional is preparing to administer dextrose 5% in water (D5W) 1,000-mL IV to infuse over 10 hr. How many mL/hr should the IV infusion pump be set to deliver? (Round the answer to the nearest whole number. Do not use a trailing zero.)

• A. 100 mL/hr
• B. 150 mL/hr
• C. 75 mL/hr
• D. 50 mL/hr

Correct answer: A

Rationale: To infuse 1,000 mL over 10 hr, the IV pump should be set to deliver 100 mL/hr. This calculation is derived by dividing the total volume (1,000 mL) by the total time in hours (10 hr), resulting in the infusion rate of 100 mL/hr. Choices B, C, and D are incorrect as they do not accurately reflect the correct calculation for this scenario.

2. A client with chronic kidney disease is being assessed. Which laboratory value would be most concerning?

• A. Serum creatinine of 3.0 mg/dL
• B. Blood urea nitrogen (BUN) of 45 mg/dL
• C. Serum potassium of 6.5 mEq/L
• D. Hemoglobin of 10 g/dL

Correct answer: C

Rationale: In a client with chronic kidney disease, an elevated serum potassium level (hyperkalemia) is the most concerning finding. Hyperkalemia can lead to life-threatening cardiac dysrhythmias due to its effect on the electrical conduction system of the heart. Monitoring and managing serum potassium levels are crucial in patients with chronic kidney disease to prevent serious complications. While elevated serum creatinine (Choice A) and Blood Urea Nitrogen (BUN) levels (Choice B) indicate impaired kidney function, hyperkalemia poses an immediate risk of cardiac complications. Hemoglobin levels (Choice D) are typically lower in chronic kidney disease due to decreased erythropoietin production, but they do not present an immediate life-threatening risk like hyperkalemia.

3. The client is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which finding indicates that the bladder irrigation is effective?

• A. The client reports minimal pain and discomfort.
• B. The urine appears clear and free of clots.
• C. The client has no signs of infection.
• D. The client is able to void independently.

Correct answer: B

Rationale: The presence of clear urine free of clots is an indicator that the bladder irrigation is effective. This finding suggests that the irrigation is preventing clot formation and ensuring proper drainage, which is crucial after a TURP procedure. The client reporting minimal pain and discomfort (choice A) may be a positive sign but does not directly reflect the effectiveness of the bladder irrigation. The absence of infection signs (choice C) is important but not specific to evaluating the bladder irrigation. The client being able to void independently (choice D) is a good sign overall but does not specifically indicate the effectiveness of the bladder irrigation.

4. The client is preparing for discharge following treatment for heart failure. Which statement by the client indicates a need for further teaching?

• A. I will weigh myself every day at the same time.
• B. I will call my doctor if my legs swell more.
• C. I will take my water pill only when I feel short of breath.
• D. I will limit the amount of salt in my diet.

Correct answer: C

Rationale: The correct answer is C. Taking water pills (diuretics) only when feeling short of breath is incorrect. Diuretics should be taken regularly as prescribed to manage fluid retention. Option A is correct as daily weight monitoring helps track for fluid retention. Option B is correct as worsening leg swelling should prompt contacting the healthcare provider. Option D is correct as limiting salt intake is essential in managing heart failure. Therefore, option C is the statement that indicates a need for further teaching.

5. During a dressing change, a healthcare professional observes granulation tissue in a client's wound. Which of the following findings should be documented?

• A. Stringy, white tissue
• B. Translucent, red tissue
• C. Soft, yellow tissue
• D. Thick, black tissue

Correct answer: B

Rationale: Granulation tissue is a hallmark of healing in wounds. It appears as translucent and red, indicating angiogenesis and the formation of new blood vessels in the wound bed. This tissue is vital for wound healing as it provides a scaffold for cell migration and promotes re-epithelialization. Choices A, C, and D do not describe granulation tissue accurately. Stringy, white tissue may suggest fibrin, soft, yellow tissue could indicate slough, and thick, black tissue may imply necrotic tissue, all of which are not synonymous with granulation tissue and do not signify the healing process.

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