Nursing Elites

1. The nurse needs to add a medication to a liter of 5% Dextrose in Water (D5W) that is already infusing into a client. At what location should the nurse inject the medication?

• A. Medication port
• B. IV drip chamber
• C. Y-site connector
• D. At the hub of the IV catheter

Correct answer: A

Rationale: The correct answer is the medication port. When adding medication to an already infusing IV solution, it should be done through the medication port to ensure direct delivery into the bloodstream without interrupting the primary IV line. Injecting the medication into the IV drip chamber, Y-site connector, or at the hub of the IV catheter can lead to dilution, inaccurate dosing, or potential blockages in the IV line, which can compromise the effectiveness of the medication and patient safety.

2. The nurse enters a client's room and observes the unlicensed assistive personnel (UAP) making an occupied bed. What action should the nurse take first?

• A. Place the side rails in an up position.
• B. Assist the UAP in turning the client.
• C. Provide instructions on proper bed-making techniques.
• D. Ask the client if they are comfortable.

Correct answer: A

Rationale: The correct answer is to place the side rails in an up position first. This action is essential to prevent the client from falling while the bed is being made. Assisting the UAP in turning the client (Choice B) is not the immediate priority. Providing instructions on bed-making techniques (Choice C) can wait until the safety of the client is ensured. Asking the client if they are comfortable (Choice D) is important but should come after ensuring the client's safety by raising the side rails.

3. The nurse is caring for a client with a tracheostomy who has thick, tenacious secretions. Which assessment finding requires immediate intervention?

• A. Crepitus around the tracheostomy site
• B. Dry and cracked tracheostomy site
• C. Mucous plugging of the tracheostomy tube
• D. Yellowing of the skin around the tracheostomy site

Correct answer: C

Rationale: Mucous plugging of the tracheostomy tube is the most concerning assessment finding in a client with a tracheostomy. It can lead to airway obstruction, which requires immediate intervention to ensure the client's airway remains patent. Crepitus around the tracheostomy site may indicate subcutaneous emphysema but is not as urgent as a blocked airway. A dry and cracked tracheostomy site may indicate poor skin integrity but does not pose an immediate threat to the client's airway. Yellowing of the skin around the tracheostomy site could suggest a localized infection, but it is not as critical as a potential airway obstruction caused by mucous plugging.

4. A client with type 1 diabetes is admitted with diabetic ketoacidosis (DKA). Which clinical finding is most concerning?

• A. Serum glucose of 500 mg/dL
• B. Serum glucose of 600 mg/dL
• C. Serum potassium of 5.5 mEq/L
• D. Serum bicarbonate of 18 mEq/L

Correct answer: D

Rationale: A serum bicarbonate level of 18 mEq/L is most concerning in a client with DKA as it indicates metabolic acidosis, requiring immediate intervention. In DKA, the body produces excess ketones, leading to metabolic acidosis. A low serum bicarbonate level is a key indicator of this acid-base imbalance. Elevated serum glucose levels are expected in DKA but are managed through insulin therapy. Serum potassium levels can fluctuate in DKA due to insulin deficiency, but a value of 5.5 mEq/L is not as immediately concerning as metabolic acidosis. Therefore, the most critical finding in this scenario is the low serum bicarbonate level.

5. A female client reports that she drank a liter of a solution to cleanse her intestines but vomited immediately after. How many ml of fluid intake should the nurse document?

• A. 1000 ml
• B. 800 ml
• C. 760 ml
• D. 500 ml

Correct answer: C

Rationale: The correct answer is 760 ml. One liter equals 1000 ml. As the client vomited immediately after drinking, she would have expelled approximately 240 ml (1 cup). Subtracting this from the initial intake of 1000 ml gives us 760 ml as the remaining fluid intake that should be documented. Choices A, B, and D are incorrect because they do not reflect the correct calculation of subtracting the amount vomited from the initial intake.

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