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. A client with chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Which assessment finding is most concerning?

• A. Oxygen saturation of 90%
• B. Respiratory rate of 24 breaths per minute
• C. Use of accessory muscles
• D. Inspiratory crackles

Correct answer: C

Rationale: The correct answer is C: 'Use of accessory muscles.' In a client with COPD and pneumonia, the use of accessory muscles indicates increased work of breathing. This finding is concerning as it may signal respiratory failure, requiring immediate intervention. Oxygen saturation of 90% (choice A) is low but not as immediately concerning as the increased work of breathing. A respiratory rate of 24 breaths per minute (choice B) is slightly elevated but not as critical as the use of accessory muscles. Inspiratory crackles (choice D) may be present in pneumonia but are not as indicative of impending respiratory failure as the increased work of breathing shown by the use of accessory muscles.

3. Following a lumbar puncture, a client voices several complaints. What complaint indicates to the nurse that the client is experiencing a complication?

• A. I am having pain in my lower back when I move my legs
• B. My throat hurts when I swallow
• C. I feel sick to my stomach and am going to throw up
• D. I have a headache that gets worse when I sit up

Correct answer: D

Rationale: The correct answer is D. A post-lumbar puncture headache, ranging from mild to severe, may occur as a result of leakage of cerebrospinal fluid at the puncture site. This complication is usually managed by bed rest, analgesics, and hydration. Choices A, B, and C do not directly indicate complications associated with a lumbar puncture. Pain in the lower back when moving legs, a sore throat when swallowing, and nausea with a feeling of vomiting are not typical complications of lumbar puncture.

4. During the initial newborn assessment, the nurse finds that a newborn's heart rate is irregular. Which intervention should the nurse implement?

• A. Notify the pediatrician immediately.
• B. Teach the parents about congenital heart defects.
• C. Document the finding in the infant's record.
• D. Apply oxygen via nasal cannula at 3 L/min.

Correct answer: C

Rationale: The correct intervention when a nurse finds an irregular heart rate in a newborn is to document the finding in the infant's record. An irregular heart rate is a common occurrence in newborns and does not necessarily require immediate medical intervention. Notifying the pediatrician immediately is unnecessary unless there are other concerning symptoms. Teaching the parents about congenital heart defects is not the priority in this situation. Applying oxygen via nasal cannula at 3 L/min is not indicated for an irregular heart rate without further assessment or medical indication.

5. A client is admitted with a diagnosis of sepsis. Which assessment finding is most concerning to the nurse?

• A. Temperature of 101.5°F
• B. Heart rate of 110 beats per minute
• C. Respiratory rate of 24 breaths per minute
• D. Blood pressure of 90/60 mmHg

Correct answer: D

Rationale: A blood pressure of 90/60 mmHg in a client with sepsis is concerning for septic shock, a life-threatening condition that requires immediate intervention. Hypotension is a severe manifestation of sepsis that can lead to poor tissue perfusion and organ failure. While the other assessment findings such as an elevated temperature, increased heart rate, and respiratory rate are also common in sepsis, hypotension is particularly alarming as it indicates a critical state of shock and necessitates urgent medical attention.

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