Nursing Elites

1. A client has developed phlebitis at the IV site. What is the next step the nurse should take?

• A. Administer an anti-inflammatory medication
• B. Discontinue the IV and notify the provider
• C. Apply a cold compress over the IV site
• D. Increase the IV flow rate to prevent dehydration

Correct answer: B

Rationale: When a client develops phlebitis at the IV site, the nurse's immediate action should be to discontinue the IV and notify the healthcare provider. Phlebitis is inflammation of the vein, and leaving the IV in place can lead to complications such as infection or thrombosis. Administering an anti-inflammatory medication (choice A) may not address the root cause and delay the necessary intervention. Applying a cold compress (choice C) may provide temporary relief but does not address the need to remove the source of inflammation. Increasing the IV flow rate (choice D) is contraindicated as it can exacerbate the phlebitis by causing more irritation to the vein.

2. A nurse is collecting data from a male client who is scheduled for a left inguinal herniorrhaphy. Which of the following findings is the priority for the nurse to report to the provider?

• A. High blood pressure
• B. Decreased bowel sounds
• C. Constipation
• D. Difficulty urinating

Correct answer: D

Rationale: The correct answer is 'Difficulty urinating.' This finding is crucial to report promptly as it can indicate a complication, such as urinary retention or injury to the urinary tract, which are significant concerns post-hernia surgery. High blood pressure (Choice A) may require monitoring but is not as urgent as difficulty urinating. Decreased bowel sounds (Choice B) and constipation (Choice C) are common after surgery and may resolve with appropriate interventions but are not as critical as addressing difficulty urinating.

3. A healthcare professional is caring for a client with coronary artery disease (CAD) who is prescribed aspirin. Which of the following findings should the healthcare professional report to the provider?

• A. A history of gastrointestinal bleeding
• B. A history of hypertension
• C. A platelet count of 180,000/mm³
• D. A prothrombin time (PT) of 12 seconds

Correct answer: A

Rationale: The correct answer is A: A history of gastrointestinal bleeding. Patients with a history of gastrointestinal bleeding are at increased risk of complications when taking aspirin due to its effects on platelet function and the gastrointestinal tract. Reporting this finding to the provider is crucial to ensure patient safety. Choices B, C, and D are not directly related to the increased risk associated with aspirin use in patients with a history of gastrointestinal bleeding, making them less relevant in this scenario. While monitoring platelet count and PT are important in patients taking aspirin, a history of gastrointestinal bleeding takes precedence as it directly impacts the safety and effectiveness of aspirin therapy in this client.

4. A client with COPD is being cared for by a nurse. Which of the following interventions should the nurse include in the plan of care?

• A. Administer oxygen at 2 L/min via nasal cannula
• B. Encourage pursed-lip breathing
• C. Position the client in high Fowler's position
• D. Encourage deep breathing and coughing

Correct answer: B

Rationale: The correct intervention for a client with COPD is to encourage pursed-lip breathing. Pursed-lip breathing helps maintain airway patency by preventing the collapse of small airways during exhalation, improving breathing efficiency. Administering oxygen at 2 L/min via nasal cannula may be appropriate for some COPD patients but is not the priority intervention. Positioning the client in high Fowler's position may help improve breathing but is not as specific as pursed-lip breathing for COPD. Encouraging deep breathing and coughing may be beneficial in other respiratory conditions, but it is not the most effective intervention for COPD.

5. What are the primary differences between Type 1 and Type 2 diabetes in terms of pathophysiology and treatment?

• A. Type 1: No insulin production; Type 2: Insulin resistance
• B. Type 1: Insulin resistance; Type 2: Insulin deficiency
• C. Type 1: Autoimmune; Type 2: Lifestyle-related
• D. Type 1: Insulin therapy; Type 2: Diet modification

Correct answer: A

Rationale: The correct answer is A. Type 1 diabetes is characterized by the absence of insulin production, while Type 2 diabetes involves insulin resistance. Choice B is incorrect because Type 1 diabetes is not related to insulin resistance. Choice C is inaccurate as Type 1 diabetes is autoimmune while Type 2 diabetes is more associated with lifestyle factors. Choice D is not correct since insulin therapy is primarily used in Type 1 diabetes, whereas diet modification is a common approach in managing Type 2 diabetes.

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