Nursing Elites

1. You are called to your patients room by a family member who voices concern about the patients status. On assessment, you find the patient tachypnic, lethargic, weak, and exhibiting a diminished cognitive ability. You also find 3+ pitting edema. What electrolyte imbalance is the most plausible cause of this patients signs and symptoms?

• A. Hypocalcemia
• B. Hyponatremia
• C. Hyperchloremia
• D. Hypophosphatemia

Correct answer: C

Rationale:

2. A home care nurse prepares to administer intravenous medication to a client. The nurse assesses the site and reviews the clients chart prior to administering the medication: Client: Thomas Jackson DOB: 5/3/1936 Gender: Male January 23 (Today): Right uppe

• A. Notify the health care provider
• B. . Administer the prescribed medication.
• C. Discontinue the PICC
• D. Switch the medication to the oral route

Correct answer: B

Rationale:

3. A nurse is caring for a client who has a serum calcium level of 14 mg/dL. Which provider order should the nurse implement first?

• A. Encourage oral fluid intake.
• B. Connect the client to a cardiac monitor.
• C. Assess urinary output.
• D. Administer oral calcitonin (Calcimar).

Correct answer: A

Rationale: The correct answer is to encourage oral fluid intake. With a serum calcium level of 14 mg/dL, the client is at risk of hypercalcemia. Encouraging oral fluid intake helps to promote hydration and can help prevent further elevation of calcium levels. Connecting the client to a cardiac monitor (Choice B) is important but not the first priority in this situation. Assessing urinary output (Choice C) is relevant but does not address the immediate concern of high serum calcium levels. Administering oral calcitonin (Calcimar) (Choice D) may be a treatment option later, but the first step should be to address hydration.

4. Which hormones increase the amount of water in the body?

• A. ADH
• B. Aldosterone
• C. ANH
• D. ADH and aldosterone

Correct answer: D

Rationale: The correct answer is D, ADH and aldosterone. Both antidiuretic hormone (ADH) and aldosterone increase water retention by the kidneys, thereby increasing blood volume. ADH acts on the kidneys to increase water reabsorption, while aldosterone acts on the kidneys to promote sodium reabsorption, leading to water retention. Choice A, ADH, is partially correct as it alone increases water retention. Choice B, aldosterone, is also partially correct as it alone increases water retention. Choice C, ANH (atrial natriuretic hormone), actually decreases water retention by promoting sodium excretion and inhibiting aldosterone release.

5. 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.

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