Nursing Elites

1. A patient has questioned the nurses administration of IV normal saline, asking whether sterile water would be a more appropriate choice than saltwater. Under what circumstances would the nurse administer electrolyte-free water intravenously?

• A. Never, because it rapidly enters red blood cells, causing them to rupture.
• B. When the patient is severely dehydrated resulting in neurologic signs and symptoms
• C. When the patient is in excess of calcium and/or magnesium ions
• D. When a patients fluid volume deficit is due to acute or chronic renal failure

Correct answer: A

Rationale:

2. . You are caring for a patient who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Your patients plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to as

• A. Nutritional status
• B. Potassium balance
• C. Calcium balance
• D. Fluid volume status

Correct answer: D

Rationale:

3. When preparing a site for the insertion of an IV catheter, how should excess hair at the site be treated?

• A. Leaving the hair intact
• B. Shaving the area
• C. Clipping the hair in the area
• D. Removing the hair with a depilatory

Correct answer: C

Rationale: The correct answer is to clip the hair in the area. Excess hair at the site of IV catheter insertion should be removed because it can be a potential source of infection. Clipping the hair is preferred over shaving because shaving can cause skin abrasions, increasing the risk of infection. Using depilatories is not recommended as they can irritate the skin, which is undesirable when preparing a clean site for an invasive procedure. Therefore, clipping the hair in the area is the most appropriate and safe method to prepare the site for IV catheter insertion.

4. The nurse is admitting a patient with a suspected fluid imbalance. The most sensitive indicator of body fluid balance is:

• A. Daily weight
• B. Serum sodium levels
• C. Measured intake and output
• D. Blood pressure

Correct answer: A

Rationale: Daily weight is the most sensitive indicator of body fluid balance because it can show trends over time, helping in assessing the effectiveness of interventions and medications. While serum sodium levels provide objective data on electrolyte balance, they may not accurately reflect fluid balance, especially if a patient is dehydrated. Measured intake and output are crucial for assessing fluid balance, but it can be challenging to match the two due to various ways fluid is lost from the body. Blood pressure and other vital signs may not always be reliable indicators of fluid balance as they can be influenced by other factors beyond fluid status.

5. The nurse in the medical ICU is caring for a patient who is in respiratory acidosis due to inadequate ventilation. What diagnosis could the patient have that could cause inadequate ventilation?

• A. Endocarditis
• B. Multiple myeloma
• C. Guillain-Barr syndrome
• D. Overdose of amphetamines

Correct answer: C

Rationale:

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