Nursing Elites

1. A client in the emergency department is severely dehydrated and is prescribed 3 L of intravenous fluid over 6 hours. At what rate (mL/hr) should the nurse set the intravenous pump to infuse the fluids? (Record your answer using a whole number.)

• A. 500 mL/hr
• B. 400 mL/hr
• C. 550 mL/hr
• D. 600 mL/hr

Correct answer: A

Rationale: To calculate the rate of the intravenous pump, divide the total volume of fluid (3 L = 3000 mL) by the total time in hours (6 hours), which equals 500 mL/hr. The correct answer is A. Choice B (400 mL/hr) is incorrect as it would result in a slower infusion rate. Choice C (550 mL/hr) and Choice D (600 mL/hr) are incorrect as they would result in a faster infusion rate, exceeding the prescribed amount of fluid to be infused over 6 hours.

2. Prior to a percutaneous kidney biopsy, which actions should a nurse take? (Select all that apply.)

• A. Keep the client NPO for 4 to 6 hours.
• B. Obtain coagulation study results.
• C. Maintain strict bedrest in a supine position.
• D. A & B

Correct answer: D

Rationale: Prior to a percutaneous kidney biopsy, the nurse should ensure that the client is kept NPO for 4 to 6 hours to prevent aspiration during the procedure. Obtaining coagulation study results is crucial to assess the risk of bleeding during and after the biopsy. Strict bedrest in a supine position is not necessary before the procedure. It is important to note that blood pressure medications should be carefully managed, but it is not a pre-procedure action. Keeping the client on bedrest or assessing for blood in the urine are interventions that are more relevant post-procedure to monitor for complications.

3. In assessing cancer risk, which woman is at greatest risk of developing breast cancer?

• A. A 35-year-old multipara who never breastfed.
• B. A 50-year-old whose mother had unilateral breast cancer.
• C. A 55-year-old whose mother-in-law had bilateral breast cancer.
• D. A 20-year-old whose menarche occurred at age 9.

Correct answer: B

Rationale: The correct answer is B because family history of breast cancer, specifically in the mother, is a significant risk factor for developing breast cancer. The age of 50 is also a risk factor for breast cancer. Choice A is less likely as breastfeeding can actually reduce the risk of breast cancer. Choice C is less relevant since the risk is higher with a direct family member. Choice D, although early menarche is a risk factor, the age of the individual is much lower compared to the other age-related risk factors.

4. An obese client with emphysema who smoked at least a pack of cigarettes daily is admitted after experiencing a sudden increase in dyspnea and activity intolerance. Oxygen therapy is initiated, and it is determined that the client will be discharged with oxygen. Which information is most important for the nurse to emphasize in the discharge teaching plan?

• A. Methods for weight loss
• B. Guidelines for oxygen use
• C. Approaches to conserve energy
• D. Strategies for smoking cessation

Correct answer: B

Rationale: In this scenario, the priority for the nurse to emphasize in the discharge teaching plan is the 'Guidelines for oxygen use.' As the client with emphysema is being discharged with oxygen therapy, it is crucial for the nurse to ensure that the client understands how to use oxygen properly to prevent complications and promote effective management of the condition. While weight loss, conserving energy, and smoking cessation are important aspects of care for this client, in this specific case, ensuring the safe and appropriate use of supplemental oxygen takes precedence to optimize the client's respiratory function and overall well-being.

5. Which of the following is a common complication of immobility?

• A. Muscle hypertrophy.
• B. Pressure ulcers.
• C. Bone fractures.
• D. Joint stiffness.

Correct answer: B

Rationale: The correct answer is B, Pressure ulcers. Immobility can lead to pressure ulcers due to prolonged pressure on the skin, especially over bony prominences. Muscle hypertrophy (Choice A) is not a common complication of immobility; instead, muscle atrophy is more likely to occur due to disuse. Bone fractures (Choice C) can result from trauma but are not directly associated with immobility unless there is a fall or accident. Joint stiffness (Choice D) can develop due to lack of movement but is not as common or severe as pressure ulcers in cases of prolonged immobility.

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