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. A client with gastroesophageal reflux disease (GERD) has been experiencing severe reflux during sleep. Which recommendation by the nurse is most effective to assist the client?

• A. Losing weight.
• B. Decreasing caffeine intake.
• C. Avoiding large meals.
• D. Raising the head of the bed on blocks.

Correct answer: D

Rationale: The correct answer is to raise the head of the bed on blocks (reverse Trendelenburg position). This elevation helps reduce reflux by using gravity to keep stomach contents from flowing back into the esophagus during sleep. Losing weight (Choice A) could be beneficial in managing GERD, but it may not be as effective for immediate relief during sleep. Decreasing caffeine intake (Choice B) and avoiding large meals (Choice C) are also valuable recommendations to manage GERD; however, they may not specifically address the issue of reflux during sleep as directly and effectively as elevating the head of the bed.

3. A client receiving warfarin (Coumadin) therapy should have which of the following laboratory results reviewed to evaluate the effectiveness of the therapy?

• A. Complete blood count (CBC).
• B. Prothrombin time (PT).
• C. International normalized ratio (INR).
• D. Partial thromboplastin time (PTT).

Correct answer: C

Rationale: The correct answer is C: International normalized ratio (INR). The INR is the most appropriate laboratory result to review when evaluating the effectiveness of warfarin (Coumadin) therapy. Warfarin is an anticoagulant medication, and the INR helps determine if the dosage is within a therapeutic range to prevent clotting or bleeding complications. Choice A, a Complete Blood Count (CBC), provides information about the cellular components of blood but does not directly assess the anticoagulant effects of warfarin. Choice B, Prothrombin time (PT), measures the time it takes for blood to clot but is not as specific for monitoring warfarin therapy as the INR. Choice D, Partial Thromboplastin Time (PTT), evaluates the intrinsic pathway of coagulation and is not the primary test used to monitor warfarin therapy.

4. During a routine clinic visit, a nurse is assessing a 48-year-old client with a history of smoking. The client, who exercises regularly, reports calf pain during exercise that disappears at rest. Which of the following findings requires further evaluation?

• A. Heart rate of 57 bpm.
• B. SpO2 of 94% on room air.
• C. Blood pressure of 134/82.
• D. Ankle-brachial index of 0.65.

Correct answer: D

Rationale: An Ankle-Brachial Index of 0.65 suggests moderate arterial vascular disease in a client experiencing intermittent claudication, indicating compromised blood flow to the lower extremities during exercise. This finding requires further evaluation to assess the severity of arterial insufficiency and determine appropriate interventions. Choice A (Heart rate of 57 bpm) is within the normal range for an adult at rest and indicates good cardiovascular fitness. Choice B (SpO2 of 94% on room air) is slightly lower than the normal range but is generally acceptable in a healthy individual. Choice C (Blood pressure of 134/82) falls within the normal range and does not raise immediate concerns in this context.

5. What is a key intervention for a patient with diabetic ketoacidosis (DKA)?

• A. Administering insulin
• B. Administering IV fluids
• C. Administering oral glucose
• D. Administering oral fluids

Correct answer: A

Rationale: Administering insulin is a crucial intervention for a patient with diabetic ketoacidosis (DKA) because it helps in managing hyperglycemia and ketosis by promoting the uptake of glucose by cells and inhibiting the production of ketones. IV fluids are necessary to correct dehydration and electrolyte imbalances commonly seen in DKA but are not the primary treatment for the condition. Administering oral glucose would exacerbate hyperglycemia in a patient with DKA, while administering oral fluids alone would not effectively address the underlying metabolic disturbances seen in DKA.

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