Nursing Elites

1. You are caring for a patient admitted with a diagnosis of acute kidney injury. When you review your patients most recent laboratory reports, you note that the patients magnesium levels are high. You should prioritize assessment for which of the followin

• A. Diminished deep tendon reflexes
• B. Tachycardia
• C. Cool, clammy skin
• D. Acute flank pain

Correct answer: A

Rationale:

2. What would be the best initial nursing action prior to inserting an IV?

• A. Instruct the patient to wash their hands.
• B. Prepare the IV insertion site with povidone iodine.
• C. Verify the order for IV therapy.
• D. Identify a suitable vein.

Correct answer: C

Rationale: The best initial nursing action prior to inserting an IV is to verify the order for IV therapy. This step ensures that the IV insertion is appropriate and necessary based on the physician's orders. Instructing the patient to wash their hands (Choice A) is important for infection control but not the immediate priority before IV insertion. While preparing the IV insertion site with povidone iodine (Choice B) and identifying a suitable vein (Choice D) are crucial steps in the process, confirming the order for IV therapy (Choice C) takes precedence to ensure the correct intervention is being performed.

3. Which substance dissociates into ions in a water solution?

• A. Intracellular fluid
• B. Interstitial fluid
• C. Plasma
• D. Electrolyte

Correct answer: D

Rationale: The correct answer is 'Electrolyte.' Electrolytes are substances that dissociate into ions when dissolved in water. Intracellular fluid, interstitial fluid, and plasma are not substances that dissociate into ions in a water solution. Intracellular fluid is the fluid inside cells, interstitial fluid is the fluid between cells, and plasma is the liquid component of blood. These choices do not dissociate into ions in a water solution, unlike electrolytes.

4. A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention should the nurse implement to prevent injury while in the hospital?

• A. Ask family members to speak quietly to keep the client calm.
• B. Assess urine color, amount, and specific gravity each day.
• C. Encourage the client to drink at least 1 liter of fluids each shift.
• D. Dangle the client on the bedside before ambulating.

Correct answer: D

Rationale: The correct answer is to 'dangle the client on the bedside before ambulating.' This intervention helps prevent orthostatic hypotension, a drop in blood pressure when changing positions, which is crucial in preventing falls and related injuries in older adult clients. Asking family members to speak quietly (Choice A) may help keep the client calm but does not directly address the risk of injury. Assessing urine parameters (Choice B) is important for monitoring hydration status but does not specifically prevent injury. Encouraging increased fluid intake (Choice C) is essential for managing dehydration but does not directly address the risk of injury during ambulation.

5. Extracellular fluid includes:

• A. plasma and intracellular fluid.
• B. interstitial and intracellular fluids.
• C. plasma and interstitial fluid.
• D. plasma, interstitial fluid, and intracellular fluid.

Correct answer: C

Rationale: The correct answer is C: 'plasma and interstitial fluid.' Extracellular fluid consists of all body fluids outside the cells, primarily including plasma (the liquid component of blood) and interstitial fluid (the fluid between cells). Choices A, B, and D are incorrect because intracellular fluid is located within the cells, not in the extracellular fluid compartment.

Similar Questions