Nursing Elites

1. A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as infiltration?

• A. purulent exudate
• B. warmth
• C. skin blanching
• D. bleeding

Correct answer: C

Rationale: Infiltration occurs when the IV fluid leaks into the surrounding tissue instead of entering the bloodstream properly. Skin blanching, swelling, and coolness at the IV site are typical signs of infiltration. Purulent exudate (choice A) is associated with infection, warmth (choice B) can indicate phlebitis, and bleeding (choice D) may occur if the IV catheter punctures a blood vessel.

2. A healthcare provider is providing teaching to a client who has a new medication prescription. Which of the following manifestations of a mild allergic reaction should the healthcare provider include?

• A. Ptosis
• B. Hematuria
• C. Urticaria
• D. Nausea

Correct answer: C

Rationale: Urticaria, also known as hives, is a common manifestation of a mild allergic reaction. Ptosis refers to drooping of the eyelid and is not typically associated with allergic reactions. Hematuria indicates blood in the urine and is not a typical allergic reaction symptom. Nausea can occur with various conditions, but it is not a specific manifestation of a mild allergic reaction.

3. A client will require oxygen therapy at home. Which of the following statements should the nurse identify as an indication that the client understands how to manage this therapy at home?

• A. I'll make sure that, when my friend comes by, they smoke at least 6 feet away from my oxygen tank.
• B. I'll use a cotton blanket if I get chilly while I'm using my oxygen.
• C. I'll check the wires and cables on my oxygen equipment to make sure they are in good working order.
• D. I'll secure my oxygen tank in an upright position to prevent it from being knocked over.

Correct answer: C

Rationale: The correct answer is C. Ensuring the oxygen equipment's wires and cables are in good working order is crucial to prevent sparks in an oxygen-rich environment, which could lead to a fire. Choices A, B, and D are incorrect because smoking near an oxygen tank, using a cotton blanket near oxygen (as cotton is less likely to generate static electricity than wool), and laying the oxygen tank down on the floor pose significant safety risks and are not appropriate practices for managing oxygen therapy at home.

4. A nurse is caring for a client who has herpes zoster. The client asks about complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies?

• A. Acupuncture
• B. Massage therapy
• C. Aromatherapy
• D. Herbal supplements

Correct answer: A

Rationale: The correct answer is A, Acupuncture. Acupuncture is contraindicated for clients with herpes zoster due to the risk of infection at the needle sites. In individuals with herpes zoster, the skin's integrity is compromised, increasing susceptibility to infections. Therefore, acupuncture, which involves inserting needles into the skin, can introduce pathogens and lead to local infections. Massage therapy (B), aromatherapy (C), and herbal supplements (D) do not involve skin penetration like acupuncture and are generally considered safe complementary therapies for pain control in clients with herpes zoster.

5. A client has left lower atelectasis. In which of the following positions should the nurse place the client for postural drainage?

• A. Supine and low Fowler's position
• B. Right lateral in Trendelenburg position
• C. Side lying with the right side of the chest elevated
• D. Prone with pillows under the extremities

Correct answer: B

Rationale: Postural drainage is a technique used to help remove secretions from specific lung segments. For left lower atelectasis, placing the client in the right lateral Trendelenburg position is most effective. This position helps target the affected area, using gravity to assist in drainage. Placing the client in a supine or low Fowler's position (Choice A) may not effectively target the affected area. Side lying with the right side of the chest elevated (Choice C) would not utilize gravity for optimal drainage. Placing the client prone with pillows under the extremities (Choice D) is not ideal for postural drainage of the left lower lobe.

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