Nursing Elites

1. An older female client has normal saline infusing at 45 mL/hour. She complains of pain at the insertion site of the IV catheter. There is no redness or edema around the IV site. Which action should the nurse take?

• A. Determine which IV medications have recently been administered.
• B. Explain that without redness or edema, there is no need to re-start the IV.
• C. Consult with the healthcare provider about the best location to start a new IV.
• D. Convert the IV to a saline lock and continue to monitor the site.

Correct answer: D

Rationale: Converting the IV to a saline lock and continuing to monitor the site is the correct action in this scenario. When a client complains of pain at the IV insertion site without redness or edema, it may indicate phlebitis or irritation. Replacing the IV may not be necessary if there are no signs of infection or infiltration. Determining the IV medications administered or consulting with the healthcare provider to start a new IV are not immediate actions required for pain management at the insertion site. Therefore, the most appropriate intervention is to convert the IV to a saline lock and closely observe for any changes or complications.

2. If a client displays risk factors for coronary artery disease, such as smoking cigarettes, eating a diet high in saturated fat, or leading a sedentary lifestyle, techniques of behavior modification may be used to help the client change the behavior. The nurse can best reinforce new adaptive behaviors by:

• A. Explaining how the risk factor behaviors lead to poor health.
• B. Withholding praise until the new behavior is well established.
• C. Rewarding the client whenever the acceptable behavior is performed.
• D. Instilling mild fear in the client to extinguish the behavior.

Correct answer: C

Rationale: The correct answer is C. A fundamental principle of behavior modification is that behavior that is rewarded is more likely to be continued. Therefore, rewarding the client whenever the acceptable behavior is performed is the best approach to reinforce new adaptive behaviors. Choice A is incorrect because simply explaining how the risk factor behaviors lead to poor health may not be as effective in promoting behavior change compared to positive reinforcement. Choice B is incorrect because withholding praise can hinder progress and motivation for the client. Choice D is incorrect because instilling fear is not a recommended method in behavior modification. It can lead to negative psychological effects and is not a sustainable approach to behavior change.

3. A client is admitted with acute kidney injury (AKI) and a urine output of 2000 mL/day. What is the major concern of the nurse regarding this client’s care?

• A. Edema and pain
• B. Electrolyte and fluid imbalance
• C. Cardiac and respiratory status
• D. Mental health status

Correct answer: B

Rationale: The major concern for a client admitted with acute kidney injury (AKI) and a high urine output of 2000 mL/day is electrolyte and fluid imbalance. In AKI, there may be an inflammatory cause leading to proteins entering the glomerulus, resulting in fluid being held in the filtrate and causing polyuria. Electrolyte loss and fluid balance are critical to monitor and manage in AKI cases. Edema and pain are not typically associated with fluid loss. While changes in cardiac, respiratory, and mental health status can occur if electrolyte imbalance is not addressed, the primary focus should be on managing electrolyte and fluid balance to prevent further complications.

4. Which of the following assessments is the most important for a patient receiving IV potassium?

• A. Respiratory rate
• B. Heart rate
• C. Blood pressure
• D. Oxygen saturation

Correct answer: C

Rationale: The most important assessment for a patient receiving IV potassium is monitoring blood pressure. IV potassium can cause significant changes in cardiac function, leading to adverse effects such as arrhythmias and cardiac arrest. While respiratory rate, heart rate, and oxygen saturation are important parameters to monitor in clinical practice, blood pressure takes precedence in patients receiving IV potassium due to its direct impact on cardiovascular function. Changes in blood pressure can be an early indicator of potassium-induced cardiac complications, making it crucial to monitor closely during administration.

5. The patient has a heart rate of 98 beats per minute and a blood pressure of 82/58 mm Hg, is lethargic, complaining of muscle weakness, and has had gastroenteritis for several days. Based on these findings, which sodium value would the nurse expect?

• A. 126 mEq/L
• B. 140 mEq/L
• C. 145 mEq/L
• D. 158 mEq/L

Correct answer: A

Rationale: The patient's presentation of tachycardia, hypotension, lethargy, muscle weakness, and gastroenteritis suggests hyponatremia. Hyponatremia is characterized by a serum sodium level below the normal range of 135-145 mEq/L. A serum sodium level of 126 mEq/L falls significantly below this range, indicating hyponatremia. Choice B (140 mEq/L) and Choice C (145 mEq/L) are within the normal range for serum sodium levels and would not explain the patient's symptoms. Choice D (158 mEq/L) is above the normal range and would indicate hypernatremia, which is not consistent with the patient's presentation.

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