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 has just returned to the nursing unit after bronchoscopy. To which intervention should the nurse give priority?

• A. Assessing the client for the return of the gag reflex
• B. Administering pain medication
• C. Encouraging copious fluid intake
• D. Ambulating the client

Correct answer: A

Rationale: After bronchoscopy, the priority intervention for the nurse is to assess the client for the return of the gag reflex. This assessment is crucial to ensure the client's safety and prevent aspiration. Keeping the client on nothing-by-mouth status until the gag reflex returns is essential. Administering pain medication, encouraging fluid intake, and ambulating the client are important interventions but assessing the gag reflex takes precedence due to the risk of aspiration post-bronchoscopy.

3. A client has an elevated blood urea nitrogen (BUN)/creatinine ratio. Which action should the nurse take first?

• A. Assess the client’s dietary habits.
• B. Inquire about the client's use of nonsteroidal anti-inflammatory drugs (NSAIDs).
• C. Hold the client’s metformin (Glucophage).
• D. Contact the health care provider immediately.

Correct answer: A

Rationale: An elevated blood urea nitrogen (BUN)/creatinine ratio can indicate various conditions such as dehydration, urinary obstruction, catabolism, or a high-protein diet. The initial action the nurse should take is to assess the client’s dietary habits to determine if the elevated ratio is related to diet. Inquiring about the use of NSAIDs is important as they can impact kidney function, but dietary causes should be ruled out first. Holding metformin or contacting the health care provider without assessing the dietary habits would be premature actions as they may not address the underlying cause of the elevated BUN/creatinine ratio.

4. The client is receiving teletherapy radiation for a malignant tumor. Which instruction regarding skin care of the portal site should the nurse provide?

• A. Protect the skin of the radiation portal site from sunlight exposure
• B. Apply moisturizing lotions daily to the radiation portal site
• C. Avoid washing the skin inside the radiation portal site
• D. Remove the ink marks of the portal after each radiation treatment

Correct answer: A

Rationale: Protecting the skin from sunlight exposure is crucial to prevent radiation burns and additional skin damage at the treatment site. Sun exposure can exacerbate skin reactions caused by radiation therapy. Applying moisturizing lotions daily may introduce foreign substances or irritants to the treated area, leading to potential complications. Washing the skin inside the radiation portal site is important for maintaining cleanliness and preventing infections. Removing the ink marks after each treatment is unnecessary and may cause unnecessary skin irritation and trauma.

5. An adult client who received partial thickness burns on 40% of the body in a house fire is admitted to the inpatient burn unit. Which fluid should the nurse prepare to administer during the client's burn recovery?

• A. 5% dextrose in water
• B. 5% dextrose in 0.25 normal saline
• C. Total parenteral nutrition
• D. Lactated Ringer's

Correct answer: D

Rationale: During the burn recovery phase, the nurse should prepare to administer Lactated Ringer's solution. Lactated Ringer's is the preferred fluid choice for burn patients as it helps replace lost fluids and electrolytes, maintain perfusion, and support organ function. Option A, 5% dextrose in water, is not the appropriate choice for fluid resuscitation in burn patients. Option B, 5% dextrose in 0.25 normal saline, does not provide the necessary electrolytes needed for burn recovery. Option C, Total parenteral nutrition, may be considered later in the treatment but is not the initial fluid of choice for burn recovery.

Similar Questions