Nursing Elites

1. The nurse is preparing to insert a peripheral IV catheter into a patient who will require fluids and IV antibiotics. How should the nurse always start the process of insertion?

• A. Leave one hand ungloved to assess the site.
• B. Cleanse the skin with normal saline.
• C. Ask the patient about allergies to latex or iodine.
• D. Remove excessive hair from the selected site.

Correct answer: C

Rationale:

2. You are performing an admission assessment on an older adult patient newly admitted for end-stage liver disease. What principle should guide your assessment of the patients skin turgor?

• A. Overhydration is common among healthy older adults.
• B. Dehydration causes the skin to appear spongy
• C. Inelastic skin turgor is a normal part of aging
• D. Skin turgor cannot be assessed in patients over 70.

Correct answer: C

Rationale:

3. A female patient is discharged from the hospital after having an episode of heart failure. She's prescribed daily oral doses of digoxin (Lanoxin) and furosemide (Lasix). Two days later, she tells her community health nurse that she feels weak and her heart 'flutters' frequently. What action should the nurse take?

• A. Tell the patient to rest more frequently.
• B. Advise the patient to discontinue digoxin and contact the physician.
• C. Contact the physician, report the symptoms, and request a blood sample to determine the patient's potassium level.
• D. Instruct the patient to avoid caffeine-containing foods.

Correct answer: C

Rationale: The correct action for the nurse to take is to contact the physician, report the patient's symptoms, and request a blood sample to determine the patient's potassium level. Furosemide, a potassium-wasting diuretic, can lead to hypokalemia, causing weakness and palpitations. Therefore, checking the potassium level is crucial in this situation. Simply telling the patient to rest more frequently won't address the underlying issue of potassium depletion. While digoxin can cause adverse effects, in this case, the symptoms are more likely related to furosemide-induced potassium loss. Instructing the patient to avoid caffeine-containing foods may be beneficial in general, but it wouldn't directly address the potassium depletion that needs urgent attention.

4. The nurse is caring for a patient in metabolic alkalosis. The patient has an NG tube to low intermittent suction for a diagnosis of bowel obstruction. What drug would the nurse expect to find on the medication orders?

• A. Cimetidine
• B. Maalox
• C. Potassium chloride elixir
• D. ) Furosemide

Correct answer: A

Rationale:

5. You are the nurse caring for a patient who is to receive IV daunorubicin, a chemotherapeutic agent. You start the infusion and check the insertion site as per protocol. During your most recent check, you note that the IV has infiltrated so you stop the infusion. What is your main concern with this infiltration?

• A. Extravasation of the medication
• B. Discomfort to the patient
• C. Blanching at the site
• D. Hypersensitivity reaction to the medication

Correct answer: A

Rationale:

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