Nursing Elites

1. While assessing a clients peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 4-cm venous cord. How should the nurse document this finding?

• A. Grade 3 phlebitis at IV site
• B. infection at IV site
• C. Thrombosed area at IV site
• D. infiltration at IV site

Correct answer: A

Rationale:

2. A patient admitted with a gastrointestinal bleed and anemia is receiving a blood transfusion. Based on the patient's hypotensive blood pressure, the nurse anticipates an order for IV fluids from the physician. Which of the following IV solutions may be administered with blood products?

• A. D5 and 0.45% Normal Saline
• B. Lactated Ringer's
• C. 5% dextrose in water
• D. 0.9% NaCl

Correct answer: D

Rationale: The correct answer is D: 0.9% NaCl. The only IV solution that can be administered with blood products is normal saline (0.9% NaCl). This solution is compatible with most blood products and is commonly used during transfusions to maintain hemodynamic stability. Choices A, B, and C are incorrect. Choice A, D5 and 0.45% Normal Saline, contains dextrose and is not recommended to be given simultaneously with blood products. Choice B, Lactated Ringer's, contains calcium, which can cause coagulation and should not be mixed with blood. Choice C, 5% dextrose in water, is hypotonic and not suitable to be administered with blood products.

3. How would a decrease in blood protein concentration impact the fluid volumes?

• A. increase interstitial fluid volume.
• B. decrease blood plasma volume.
• C. decrease interstitial fluid volume.
• D. increase interstitial fluid volume and decrease blood plasma volume.

Correct answer: D

Rationale: A decrease in blood protein concentration would lead to a reduction in osmotic pressure, which is responsible for drawing fluid back into the capillaries. This decrease in osmotic pressure would result in an increase in interstitial fluid volume as fluid moves out of the capillaries, and a decrease in blood plasma volume as less fluid is drawn back into the circulation. Therefore, the correct answer is to increase interstitial fluid volume and decrease blood plasma volume. Choices A, B, and C are incorrect because they do not reflect the impact of decreased blood protein concentration on fluid volumes.

4. A nurse in the neurologic ICU has orders to infuse a hypertonic solution into a patient with increased intracranial pressure. This solution will increase the number of dissolved particles in the patients blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. This process is best described as which of the following?

• A. Hydrostatic pressure
• B. Osmosis and osmolality
• C. Diffusion
• D. Active transport

Correct answer: B

Rationale:

5. You are the surgical nurse caring for a 65-year-old female patient who is postoperative day 1 following a thyroidectomy. During your shift assessment, the patient complains of tingling in her lips and fingers. She tells you that she has an intermittent spasm in her wrist and hand and she exhibits increased muscle tone. What electrolyte imbalance should you first suspect?

• A. Hypophosphatemia
• B. Hypocalcemia
• C. Hypermagnesemia
• D. Hyperkalemia

Correct answer: B

Rationale:

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