Nursing Elites

1. While assessing a patient's 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: Infiltration is the administration of a nonvesicant solution or medication into the surrounding tissue, typically due to the dislodgement or perforation of the vein wall by the IV cannula. It is characterized by edema around the insertion site, leakage of IV fluid, discomfort, coolness, and a decrease in flow rate. In this scenario, the presence of edema indicates infiltration, not air emboli, phlebitis, or fluid overload. Air emboli refer to air bubbles in the bloodstream, phlebitis is inflammation of the vein, and fluid overload is an excessive volume of fluid in the circulatory system.

2. A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance should the nurse assess? (Select all that do mot apply.)

• A. Electrocardiogram changes
• B. Slow, shallow respirations
• C. Paralytic ileus
• D. Skeletal muscle weakness

Correct answer: B

Rationale:

3. A nurse is caring for a client who is having a subclavian central venous catheter inserted. The client begins to report chest pain and difficulty breathing. After administering oxygen, which action should the nurse take next?

• A. Administer a sublingual nitroglycerin tablet
• B. Prepare to assist with chest tube insertion.
• C. . Place a sterile dressing over the IV site
• D. Re-position the client into the Trendelenburg position.

Correct answer: B

Rationale:

4. After teaching a client who was malnourished and is being discharged, a nurse assesses the clients understanding. Which statement indicates the client correctly understood teaching to decrease risk for the development of metabolic acidosis?

• A. I will drink at least three glasses of milk each day.
• B. . I will eat three well-balanced meals and a snack daily.
• C. . I will not take pain medication and antihistamines together.
• D. I will avoid salting my food when cooking or during meals.

Correct answer: A

Rationale:

5. The nurse assessing skin turgor in an elderly patient should remember that:

• A. Overhydration causes the skin to tent.
• B. Dehydration causes the skin to appear edematous and spongy.
• C. Inelastic skin turgor is a normal part of aging.
• D. Normal skin turgor is moist and boggy.

Correct answer: C

Rationale: Inelastic skin turgor is a normal part of aging. Dehydration, not overhydration, causes inelastic skin with tenting. Overhydration, not dehydration, causes the skin to appear edematous and spongy. Normal skin turgor is dry and firm. Choice A is incorrect because overhydration does not cause the skin to tent; it is dehydration that leads to tenting. Choice B is incorrect because dehydration, not overhydration, causes the skin to appear edematous and spongy. Choice D is incorrect because normal skin turgor is dry and firm, not moist and boggy.

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