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. You are making initial shift assessments on your patients. While assessing one patients peripheral IV site, you note edema around the insertion site. How should you document this complication related to IV therapy?

• A. Air emboli
• B. Phlebitis
• C. Infiltration
• D. Fluid overload

Correct answer: C

Rationale:

3. A nurse preparing to start an IV on a newly admitted patient teaches the patient about the procedure and begins to prepare the site. The nurse should always start by:

• A. Leaving one hand ungloved to assess the site
• B. Preparing the skin with an iodine solution
• C. Asking the patient if they are allergic to latex or iodine
• D. Removing excessive hair at the selected site

Correct answer: C

Rationale: Before preparing the skin, the nurse should ask the patient if they are allergic to latex or iodine, which are commonly used in IV therapy setup. This is crucial to prevent potential allergic reactions at the IV site or even life-threatening anaphylaxis. Leaving one hand ungloved (choice A) is not a recommended practice as both hands should be gloved for infection control. While preparing the skin with an iodine solution (choice B) is a step in the process, ensuring the patient's safety by checking for allergies comes first. Removing excessive hair at the selected site (choice D) is not necessary and can lead to skin irritation.

4. When does dehydration begin to occur?

• A. the body reduces fluid output to zero.
• B. the body increases the release of ANH.
• C. the salivary secretions decrease.
• D. the salivary secretions increase.

Correct answer: C

Rationale: Dehydration leads to a decrease in the body's fluid levels, causing the salivary glands to produce less saliva, resulting in a dry mouth. Therefore, when dehydration begins to occur, salivary secretions decrease. Choice A is incorrect because the body does not reduce fluid output to zero during dehydration; it tries to conserve fluids. Choice B is incorrect as dehydration does not directly increase the release of ANH (Atrial Natriuretic Hormone). Choice D is incorrect because salivary secretions do not increase but decrease during dehydration.

5. A patient's lab results show a slight decrease in potassium. The physician has declined to treat with drug therapy but has suggested increasing the potassium through diet. Which of the following would be a good source of potassium?

• A. Apples
• B. Asparagus
• C. Carrots
• D. Bananas

Correct answer: D

Rationale: Bananas are an excellent source of potassium, making them a good choice to increase potassium levels through diet. While apples, asparagus, and carrots are nutritious, they are not particularly high in potassium compared to bananas. Therefore, choosing bananas would be more effective in increasing the patient's potassium intake.

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