Nursing Elites

1. Which needle should the nurse use to administer intravenous fluids (IV) via a client's implanted port?

• A. The one with the clamp and no needle
• B. A butterfly needle
• C. A non-coring (Huber) needle
• D. A standard hypodermic needle

Correct answer: C

Rationale: The correct needle to use for administering intravenous fluids via an implanted port is a non-coring (Huber) needle. This type of needle is specifically designed to access implanted ports without coring the septum, which helps prevent damage. Choice A, the one with the clamp and no needle, is incorrect as it does not describe a needle suitable for accessing an implanted port. Choice B, a butterfly needle, is not typically used for accessing implanted ports. Choice D, a standard hypodermic needle, is not ideal for accessing ports as it can damage the septum.

2. A client with liver cirrhosis is admitted with ascites and jaundice. Which assessment finding is most concerning?

• A. Serum albumin of 3.0 g/dL
• B. Bilirubin of 3.0 mg/dL
• C. Ammonia level of 80 mcg/dL
• D. Prothrombin time of 18 seconds

Correct answer: C

Rationale: An ammonia level of 80 mcg/dL is elevated and concerning in a client with liver cirrhosis, as it may indicate hepatic encephalopathy. Elevated ammonia levels can lead to cognitive impairment, altered mental status, and even coma. Serum albumin, bilirubin, and prothrombin time are also important markers in liver cirrhosis but are not as directly associated with the risk of hepatic encephalopathy as elevated ammonia levels.

3. A client with a history of chronic heart failure is admitted with shortness of breath and crackles in the lungs. Which laboratory value should be closely monitored?

• A. Serum creatinine of 2.0 mg/dL
• B. Serum sodium of 135 mEq/L
• C. Serum potassium of 5.5 mEq/L
• D. Blood glucose of 150 mg/dL

Correct answer: C

Rationale: A serum potassium level of 5.5 mEq/L should be closely monitored in a client with chronic heart failure as it may indicate hyperkalemia, requiring intervention. Hyperkalemia can lead to life-threatening cardiac arrhythmias in patients with heart failure. Serum creatinine (Choice A) is important to monitor for kidney function but is not the priority in this case. Serum sodium (Choice B) and blood glucose (Choice D) levels are not typically the primary focus when assessing a client with heart failure presenting with respiratory symptoms and crackles in the lungs.

4. The nurse enters a client's room to administer scheduled daily medications and observes the client leaning forward and using pursed lip breathing. Which action is most important for the nurse to implement first?

• A. Evaluate the oxygen saturation.
• B. Administer a bronchodilator.
• C. Assist the client to sit upright.
• D. Encourage slow, deep breathing.

Correct answer: A

Rationale: In this scenario, the nurse should first evaluate the oxygen saturation. This action is crucial as it provides immediate information on the client's respiratory status. Assessing the oxygen saturation can help determine the adequacy of oxygenation and guide further interventions. Administering a bronchodilator (Choice B) may be necessary based on assessment findings, but it should not be the first action without knowing the oxygen saturation level. While assisting the client to sit upright (Choice C) is generally beneficial for respiratory function, in this case, assessing oxygen saturation takes precedence. Encouraging slow, deep breathing (Choice D) can be helpful, but it is secondary to evaluating the oxygen saturation in this situation.

5. Following an open reduction of the tibia, the nurse notes bleeding on the client's cast. Which action should the nurse implement?

• A. Outline the area with ink and check it every 15 minutes to see if the area has increased
• B. Notify the healthcare provider immediately
• C. Apply a new cast to stop the bleeding
• D. Elevate the limb to reduce blood flow

Correct answer: A

Rationale: After an open reduction of the tibia, bleeding on the cast can be a concern. Outlining the area with ink and monitoring it every 15 minutes is the appropriate action to assess if the bleeding is worsening, indicating the need for further intervention. This action allows for close observation without disturbing the cast. Choice B is incorrect because while notifying the healthcare provider is important, immediate action is not always necessary if the bleeding is not severe. Choice C is incorrect because applying a new cast is not the standard intervention for bleeding on a cast. Choice D is incorrect because elevating the limb may not address the underlying cause of bleeding and may not be the most appropriate action at this time.

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