Nursing Elites

1. When using an IV pump for a newly admitted client, what action should the nurse take?

• A. Grasp the IV pump cord when unplugging it from the electrical outlet.
• B. Ensure the pump is plugged into an outlet with two prongs.
• C. Hold the IV pump cord while walking the client.
• D. Check for malfunctioning pump alerts.

Correct answer: C

Rationale: The correct action for the nurse to take when using an IV pump for a newly admitted client is to hold the IV pump cord while walking the client. This is important for ensuring the safe and secure management of the IV pump during client mobility. Option A is incorrect as grasping the IV pump cord when unplugging it can lead to electrical hazards. Option B is incorrect as ensuring the pump is plugged into an outlet with two prongs is important for electrical safety but not directly related to the nurse's action. Option D is also important but does not directly address the nurse's immediate action while using the IV pump with the client.

2. A nurse is assessing a client who is 2 days postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

• A. Serosanguineous drainage on the dressing
• B. Heart rate of 88/min
• C. Urine output of 30 mL/hr
• D. Blood pressure of 110/70 mm Hg

Correct answer: C

Rationale: The correct answer is C because a urine output of 30 mL/hr indicates oliguria, which can be a sign of dehydration or kidney impairment postoperatively. This finding should be reported to the provider for further evaluation. Choices A, B, and D are within normal parameters for a client who is 2 days postoperative following abdominal surgery and do not raise immediate concerns. Serosanguineous drainage on the dressing is an expected finding in the early postoperative period, a heart rate of 88/min is within the normal range, and a blood pressure of 110/70 mm Hg is also within normal limits.

3. A nurse is caring for a child who has cystic fibrosis and is receiving postural drainage. Which of the following actions should the nurse take?

• A. Perform the procedure after meals.
• B. Administer bronchodilators before the procedure.
• C. Hold hand flat to perform percussion.
• D. Perform the procedure twice a day.

Correct answer: C

Rationale: The correct action the nurse should take when caring for a child with cystic fibrosis receiving postural drainage is to hold the hand flat to perform percussion. This technique allows for effective chest physiotherapy. Choice A is incorrect because postural drainage should be performed before meals to prevent vomiting during the procedure. Choice B is incorrect because bronchodilators are typically administered before postural drainage to help open up the airways. Choice D is incorrect as the frequency of postural drainage may vary depending on the individual's condition, so performing it twice a day may not be appropriate for all patients.

4. A nurse is providing discharge teaching to a client who has a new prescription for warfarin. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will avoid aspirin while taking this medication.
• B. I will increase my intake of green leafy vegetables.
• C. I will take this medication with an antacid.
• D. I should expect mild bruising around my elbows.

Correct answer: A

Rationale: The correct answer is A: "I will avoid aspirin while taking this medication." Clients taking warfarin should avoid aspirin due to the increased risk of bleeding. Choice B is incorrect because increasing the intake of green leafy vegetables high in Vitamin K can interfere with the effects of warfarin. Choice C is incorrect because warfarin should not be taken with antacids as they can decrease its absorption. Choice D is incorrect because mild bruising is a common side effect of warfarin due to its anticoagulant properties.

5. A nurse is caring for a client who has chronic kidney disease. The nurse should identify which of the following laboratory values as an indication for hemodialysis?

• A. Glomerular filtration rate of 14 mL/min
• B. BUN 16 mg/dL
• C. Serum magnesium 1.8 mg/dL
• D. Serum phosphorus 4.0 mg/dL

Correct answer: A

Rationale: A glomerular filtration rate (GFR) of 14 mL/min is significantly low, indicating poor kidney function and the need for hemodialysis to remove waste products effectively. BUN, serum magnesium, and serum phosphorus levels are important in assessing kidney function and electrolyte balance but are not direct indicators for the initiation of hemodialysis. BUN (blood urea nitrogen) reflects the kidney's ability to filter waste products, serum magnesium levels are important for muscle and nerve function, and serum phosphorus levels are vital for bone health.

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