Nursing Elites

1. A client with IV fluids has developed redness and warmth at the IV site. What is the next step the nurse should take?

• A. Apply a cold compress to the IV site
• B. Discontinue the IV and notify the healthcare provider
• C. Monitor the IV site for signs of infection
• D. Increase the IV flow rate to improve circulation

Correct answer: B

Rationale: When a client develops redness and warmth at the IV site, it is indicative of phlebitis, which is inflammation of the vein. The next step for the nurse should be to discontinue the IV and notify the healthcare provider. Applying a cold compress may provide temporary relief but does not address the underlying issue. Monitoring for infection is important, but in this case, the presence of redness and warmth suggests phlebitis, not infection. Increasing the IV flow rate can exacerbate the inflammation and should be avoided.

2. A nurse is reinforcing teaching about a clear liquid diet. What should the client avoid?

• A. Lemon-lime sports drinks
• B. Orange sherbet
• C. Black coffee
• D. Ginger ale

Correct answer: D

Rationale: The correct answer is D, Ginger ale. A clear liquid diet includes fluids that are see-through and easily digestible. Ginger ale is a carbonated beverage that is allowed on a clear liquid diet. Orange sherbet, choice B, is not suitable for a clear liquid diet as it contains dairy products and solid particles, which are not transparent. Lemon-lime sports drinks, choice A, may contain added colorings or particles that are not allowed on a clear liquid diet. Black coffee, choice C, is also not recommended on a clear liquid diet as it is not a clear liquid and contains substances that may be hard to digest.

3. How should a healthcare professional assess a patient for potential deep vein thrombosis (DVT)?

• A. Assess for unilateral leg swelling
• B. Encourage early mobilization
• C. Check for calf tenderness
• D. Observe for redness and warmth

Correct answer: A

Rationale: To assess a patient for potential deep vein thrombosis (DVT), healthcare professionals should look for unilateral leg swelling. This is a classic sign of DVT. While encouraging early mobilization is generally beneficial for preventing DVT, it is not a method of assessment. Checking for calf tenderness is also relevant but not as specific as unilateral leg swelling. Observing for redness and warmth can be signs of inflammation but are not as specific to DVT as unilateral leg swelling.

4. A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse take to prevent atelectasis?

• A. Encourage deep breathing exercises
• B. Encourage the client to cough every 2 hours
• C. Administer an incentive spirometer
• D. Assist the client to ambulate in the hallway

Correct answer: C

Rationale: The correct answer is C: Administer an incentive spirometer. Using an incentive spirometer helps prevent atelectasis by encouraging lung expansion after surgery. Encouraging deep breathing exercises (choice A) is beneficial but may not be as effective as an incentive spirometer. Encouraging the client to cough (choice B) helps with airway clearance but does not directly prevent atelectasis. Assisting the client to ambulate (choice D) is important for preventing complications such as deep vein thrombosis, but it is not the most effective intervention for preventing atelectasis.

5. What should a healthcare provider monitor in a client with constipation?

• A. Monitor the client's bowel sounds every 4 hours
• B. Increase the client's activity to stimulate bowel movement
• C. Encourage the client to use a stool softener
• D. Encourage the client to rest in bed until constipation resolves

Correct answer: C

Rationale: Encouraging the client to use a stool softener is the appropriate intervention for constipation. Stool softeners help to soften the stool, making it easier to pass and relieving constipation without straining the client. Monitoring bowel sounds (Choice A) may be relevant for other gastrointestinal issues but is not specifically indicated for constipation. Increasing activity (Choice B) can be helpful in some cases, but it is not the first-line intervention for constipation. Encouraging bed rest (Choice D) can worsen constipation by reducing mobility and promoting inactivity.

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