Nursing Elites

1. An older client is admitted to the intensive care unit unconscious after several days of vomiting and diarrhea. The nurse inserts a urinary catheter and observes dark amber urine output. Which intervention should the nurse implement first?

• A. Begin dopamine infusion at 2 mcg/kg/minute.
• B. Begin potassium chloride 10 mEq over 1 hour.
• C. Give a bolus of 0.9% sodium chloride 1000 mL over 30 minutes.
• D. Administer promethazine 25 mg IV push.

Correct answer: C

Rationale: In this scenario, the priority intervention is to give a bolus of 0.9% sodium chloride 1000 mL over 30 minutes. The client's dark amber urine output indicates dehydration and hypovolemia, requiring rapid fluid resuscitation. Dopamine infusion, potassium chloride, and promethazine are not the initial interventions needed for a client with hypovolemic symptoms.

2. A client receiving radiation therapy for breast cancer reports dry, peeling skin at the treatment site. What action should the nurse recommend?

• A. Apply lotion to the treatment area.
• B. Use mild soap and water to cleanse the area.
• C. Cover the area with a sterile dressing.
• D. Allow the skin to air dry after washing.

Correct answer: B

Rationale: The correct recommendation for a client with dry, peeling skin at a radiation therapy treatment site is to use mild soap and water to cleanse the area. This approach helps in preventing skin irritation and reduces the risk of infection. Applying lotion (Choice A) may further irritate the skin due to the chemicals present in the lotion. Covering the area with a sterile dressing (Choice C) is not necessary unless there is an open wound that needs protection. Allowing the skin to air dry after washing (Choice D) may lead to further dryness and peeling.

3. The nurse is caring for a client with fluid overload. The most reliable indicator of fluid volume status is

• A. Body weight
• B. Intake and output
• C. Daily weight
• D. Skin turgor

Correct answer: C

Rationale: Daily weight is the most reliable indicator of fluid volume status as it reflects changes in body fluid balance accurately. Body weight alone can fluctuate due to various factors, including food intake and bowel movements, which may not accurately represent fluid status. Intake and output provide information on fluid balance over time but may not reflect immediate changes. Skin turgor is a physical assessment finding that indicates hydration status, not overall fluid volume status.

4. A client with myasthenia gravis (MG) is receiving immunosuppressive therapy. Recent lab tests show decreased serum magnesium. What nursing action is most important?

• A. Observe rhythm on telemetry monitor.
• B. Check for visual difficulties.
• C. Assess for hip and hand joint pain.
• D. Note the most recent hemoglobin level.

Correct answer: A

Rationale: Magnesium plays a crucial role in maintaining normal cardiac rhythms, particularly in patients with cardiac conditions. Abnormal levels can lead to arrhythmias, which is why continuous monitoring of the heart's electrical activity is important. Magnesium's effect on neuromuscular and cardiac function makes it essential to monitor its levels, and any discrepancies can impact treatment decisions. Checking for visual difficulties (choice B) may be important in MG but is not the priority in the context of decreased serum magnesium. Assessing for hip and hand joint pain (choice C) is not directly related to the issue of decreased serum magnesium. Noting the most recent hemoglobin level (choice D) is not the priority in this situation compared to monitoring the cardiac rhythm due to low magnesium levels.

5. A client is recovering from a hip replacement surgery. What is the priority nursing intervention to prevent complications?

• A. Encourage bed rest to prevent strain on the hip
• B. Assist the client with early ambulation
• C. Provide continuous passive motion therapy
• D. Administer pain medication before activity

Correct answer: B

Rationale: The correct answer is B: Assist the client with early ambulation. Early ambulation is a key intervention to prevent complications like deep vein thrombosis (DVT) and promote circulation after hip replacement surgery. It also helps with overall recovery and reduces the risk of complications related to immobility, such as muscle atrophy and pressure ulcers. Choice A is incorrect as bed rest should be avoided to prevent complications associated with immobility. Choice C, continuous passive motion therapy, is not the priority intervention immediately post-hip replacement surgery. Choice D, administering pain medication before activity, is important but not the priority intervention to prevent complications in this case.

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