The nurse is preparing to start an IV on a newly admitted patient. Which action by the nurse places the patient at risk for infection?

The nurse applies a tourniquet to assess a vein.

The nurse dons gloves before starting the IV.

The nurse blows on the area cleansed with alcohol to dry it quickly

The nurse cleans the area with an alcohol pad

Answer and Explanation

The Correct Answer is C

A. The nurse applies a tourniquet to assess a vein: Applying a tourniquet is standard practice and does not increase infection risk if proper technique is used.

B. The nurse dons gloves before starting the IV: Wearing gloves minimizes the risk of infection for both the patient and the nurse.

C. The nurse blows on the area cleansed with alcohol to dry it quickly: Blowing on the site introduces bacteria from the nurse's breath to the cleansed area, increasing the risk of infection.

D. The nurse cleans the area with an alcohol pad: Cleaning the site with alcohol reduces the risk of infection and is standard practice.

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Correct Answer is C

Explanation

A. Urine output 20 mL/hr: A urine output of 20 mL/hr is on the low side but can still be expected in dehydration, as the body attempts to conserve water. Normal urine output is 30 mL/hr or more, so this could still be a sign of dehydration.

B. Sodium 142 mEq/L (136 to 145 mEq/L): This sodium level is within the normal range. Dehydration may cause sodium to be elevated if water loss is more significant than sodium loss, but a normal value does not indicate dehydration.

C. Cool skin: Cool skin is a typical finding in dehydration, particularly in severe cases, due to reduced peripheral circulation and vasoconstriction as the body tries to maintain core temperature and blood pressure.

D. Bradycardia: Dehydration usually causes tachycardia as a compensatory mechanism to maintain blood pressure and perfusion, not bradycardia.

A. Lactulose B. Acetylcysteine C. Sodium polystyrene (Kayexalate) D. Triamterene

Correct Answer is C

Explanation

A. Lactulose: Lactulose is used to treat hepatic encephalopathy by reducing ammonia levels, not for hyperkalemia.

B. Acetylcysteine: Acetylcysteine is used for acetaminophen overdose or as a mucolytic agent, not for hyperkalemia.

C. Sodium polystyrene (Kayexalate): Kayexalate is used to treat hyperkalemia by exchanging sodium for potassium in the intestines, promoting the elimination of potassium through the stool. This is the correct treatment for a potassium level of 6.8 mEq/L, which is dangerously high.

D. Triamterene: Triamterene is a potassium-sparing diuretic and would worsen hyperkalemia, not treat it.

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The nurse is preparing to start an IV on a newly admitted patient. Which action by the nurse places the patient at risk for infection?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has dehydration. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse is reviewing the medical record of a client and identifies a serum potassium 6.8 mEq/L (3.5-5 mEq/L). Which of the following medications should the nurse expect to administer?

Correct Answer is C

Explanation

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