Nursing Elites

1. Which of the following components is associated with hypertonic dehydration?

• A. Plasma sodium levels above 150 mEq/L
• B. Fluid moves from extracellular space to intracellular space
• C. Water loss is greater than electrolyte loss
• D. Physical signs and symptoms are grossly apparent

Correct answer: C

Rationale: The correct answer is 'Water loss is greater than electrolyte loss.' In hypertonic dehydration, there is a higher loss of water compared to electrolytes, leading to elevated concentrations of electrolytes in the body. This condition is characterized by plasma sodium levels above 150 mEq/L. As water moves from the extracellular space to the intracellular space, it results in cellular dehydration. Choice A is incorrect because the plasma sodium levels associated with hypertonic dehydration are typically above 150 mEq/L, not between 130 and 150 mEq/L. Choice B is incorrect as fluid moves from the extracellular space to the intracellular space in hypertonic dehydration. Choice D is incorrect because physical signs and symptoms may not always be grossly apparent in hypertonic dehydration.

2. Which of the following interventions is necessary before insertion of an arterial line into the radial artery?

• A. Ensure that the client does not need surgery
• B. Assess the client's grip strength
• C. Perform an Allen test
• D. Check a serum potassium level

Correct answer: C

Rationale: Before inserting an arterial line into the radial artery, it is crucial to perform an Allen test. The Allen test assesses the collateral circulation to the hand by compressing both the radial and ulnar arteries. By occluding the radial artery and releasing the ulnar artery, the nurse can check if the ulnar artery can adequately supply blood to the hand if the radial artery is cannulated. This step ensures that there is adequate circulation to the hand post-insertion of the arterial line. Choice A, ensuring that the client does not need surgery, is not directly related to the insertion of an arterial line and is not a necessary step before the procedure. Choice B, assessing grip strength, is not specific to the vascular status of the hand and does not provide information about the adequacy of collateral circulation. Choice D, checking a serum potassium level, is unrelated to the assessment of radial artery patency and collateral circulation, which are the primary concerns before arterial line insertion.

3. As a nurse, you have been assigned to take over as charge nurse without any report after the previous charge nurse fell during her shift and was taken to the emergency room. At the end of the shift, you have made the assignments for the next shift's nurses and posted them. As the nurses come in, they begin to complain that the assignments make no sense based on patient acuity. One refuses to take her assignment and threatens to go home. What could you have done to prevent their dissatisfaction?

• A. Reviewed the notes of the previous charge nurse
• B. Tried to contact the previous charge nurse in the emergency room
• C. Collaborated with the nurse manager
• D. Collaborated with the other nurses on your shift

Correct answer: D

Rationale: Collaborating with the other nurses on your shift would have permitted them to provide the most updated information regarding patient status and acuity. Requesting their input into creating assignments would have provided shared governance and assurance that the unit staffing was arranged appropriately. Reviewing the notes of the previous charge nurse might not capture the real-time changes in patient conditions. Trying to contact the previous charge nurse in the emergency room may not be feasible or timely. Collaborating with the nurse manager could be helpful, but involving the nurses directly impacted by the assignments would have been more effective in addressing their concerns and ensuring appropriate patient care.

4. Plantar flexion can be prevented with ________________.

• A. foot soaks
• B. foot boards
• C. toenail care
• D. proper shoes

Correct answer: B

Rationale: Plantar flexion, or foot drop, can be prevented with foot boards, special splints, and range of motion exercises. Foot boards help maintain the foot in a neutral position, preventing contractures and deformities. Foot soaks (choice A) may help with foot hygiene but do not directly prevent plantar flexion. Toenail care (choice C) is important for overall foot health but does not prevent plantar flexion. Proper shoes (choice D) are essential for foot support and comfort but do not specifically prevent plantar flexion.

5. The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What are the priority nursing diagnoses at this time?

• A. Altered tissue perfusion
• B. Risk for fluid volume deficit
• C. High risk for hemorrhage
• D. Risk for infection

Correct answer: D

Rationale: The correct answer is 'Risk for infection.' When membranes are ruptured for over 24 hours before delivery, there is a significantly increased risk of infection for both the mother and the newborn. Factors such as increased local cytokines, an imbalance in enzyme activity, and increased intrauterine pressure contribute to this risk. 'Altered tissue perfusion' is not the priority in this scenario as there is no indication of compromised blood flow. 'Risk for fluid volume deficit' is not the priority as there are no signs of excessive fluid loss. 'High risk for hemorrhage' is not the priority as the question does not suggest active bleeding as an immediate concern.

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