Nursing Elites

1. A client is admitted for cellulitis surrounding an insect bite on the lower right arm, and intravenous (IV) antibiotic therapy is prescribed. Which action should the nurse implement before performing venipuncture?

• A. Lower the right arm below the level of the heart.
• B. Elevate the right arm on a pillow.
• C. Apply a tourniquet above the insertion site.
• D. Apply a warm compress to the insertion site.

Correct answer: A

Rationale: Before performing venipuncture for IV therapy, the nurse should lower the right arm below the level of the heart. Lowering the arm helps dilate the veins, making it easier to locate and access a suitable vein for the procedure. Elevating the arm on a pillow, applying a tourniquet above the insertion site, or applying a warm compress to the insertion site are not appropriate actions before venipuncture as they can affect the venous blood flow and make the procedure more challenging.

2. The nurse is preparing a community education program on osteoporosis. Which instruction is helpful in preventing bone loss and promoting bone formation?

• A. Recommend weight-bearing physical activity.
• B. Encourage a diet high in dairy products.
• C. Suggest vitamin D supplementation.
• D. Advise avoiding caffeine and alcohol.

Correct answer: A

Rationale: The correct answer is A: Recommend weight-bearing physical activity. Weight-bearing exercises are effective in maintaining bone density and preventing osteoporosis by promoting bone formation. Encouraging a diet high in dairy products (choice B) can provide calcium, but it's not as directly related to bone formation as physical activity. While vitamin D supplementation (choice C) is important for calcium absorption and bone health, it is not directly involved in promoting bone formation. Advising to avoid caffeine and alcohol (choice D) can be beneficial for bone health, but it is not as directly related to promoting bone formation as weight-bearing physical activity.

3. While caring for a toddler receiving oxygen (02) via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement?

• A. Ask the mother what she usually uses on the child's lips and nose.
• B. Apply a petroleum jelly (Vaseline) to the child's nose and lips.
• C. Use a topical lidocaine (Zylocaine viscous) analgesic for cracked lips.
• D. Use a water-soluble lubricant on affected oral and nasal mucosa.

Correct answer: D

Rationale: A water-soluble lubricant is safe to use in conjunction with oxygen therapy, unlike petroleum jelly which is flammable.

4. The nurse is assessing a 1-year-old child with bronchiolitis caused by respiratory syncytial virus (RSV). Which assessment finding requires immediate intervention?

• A. Wheezing heard on expiration
• B. Oxygen saturation of 90%
• C. Respiratory rate of 40 breaths per minute
• D. Nasal flaring with sternal retractions

Correct answer: D

Rationale: Nasal flaring with sternal retractions indicates severe respiratory distress in a 1-year-old with bronchiolitis, requiring immediate intervention. Nasal flaring and sternal retractions are signs of increased work of breathing and decreased air movement, indicating the child is struggling to breathe. Wheezing on expiration (Choice A) is common in bronchiolitis but may not require immediate intervention. An oxygen saturation of 90% (Choice B) is low but may not be the most critical finding in this case. A respiratory rate of 40 breaths per minute (Choice C) is elevated but alone may not indicate the need for immediate intervention as much as nasal flaring and sternal retractions.

5. While taking vital signs, a critically ill male client grabs the nurse's hand and asks the nurse not to leave. What action is best for the nurse to take?

• A. Pull up a chair and sit beside the client's bed.
• B. Reassure the client that you will return shortly.
• C. Ask another nurse to stay with the client.
• D. Continue taking vital signs and then leave the room.

Correct answer: A

Rationale: The best action for the nurse to take in this situation is to pull up a chair and sit beside the client's bed. By doing so, the nurse can provide emotional support and comfort to the critically ill patient who is feeling vulnerable. Sitting with the client also shows empathy and a willingness to listen to the client's needs. Reassuring the client that the nurse will return shortly (Choice B) may not address the immediate need for emotional support. Asking another nurse to stay with the client (Choice C) may not establish the same level of connection and comfort as sitting with the client personally. Continuing to take vital signs and then leaving the room (Choice D) disregards the client's emotional needs in that moment.

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