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 caring for a client who has chronic obstructive pulmonary disease (COPD). Which of the following interventions should the nurse include in the plan of care?

• A. Administer oxygen at 2L/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 improve oxygenation by preventing airway collapse, slowing down the breathing rate, and promoting better gas exchange. Administering oxygen at 2L/min via nasal cannula is not the first-line intervention as it can cause oxygen toxicity in COPD patients. Positioning the client in high Fowler's position may improve ventilation but does not specifically address the breathing technique required for COPD. Encouraging deep breathing and coughing is generally not recommended for clients with COPD as it can lead to air trapping and increased work of breathing.

3. A nurse in a long-term care facility is reviewing information about health care-associated infections with a newly licensed nurse. Which of the following information should the nurse include?

• A. Frequent hand washing prevents infection
• B. Prolonged use of corticosteroids increases infection risk
• C. Limit patient interaction to reduce infection spread
• D. Restrict client movement to prevent contamination

Correct answer: B

Rationale: The correct answer is B because prolonged use of corticosteroids is a known risk factor for infections. Choice A is incorrect because frequent hand washing actually helps prevent infections. Choice C is incorrect as patient interaction is essential in healthcare but should be done following proper infection control measures. Choice D is also incorrect as restricting client movement is not a standard practice to prevent contamination.

4. How should a healthcare professional manage a patient with congestive heart failure?

• A. Administer diuretics and monitor fluid balance
• B. Provide a high-sodium diet and restrict fluids
• C. Administer oxygen and provide pain relief
• D. Provide bronchodilators and encourage mobility

Correct answer: A

Rationale: Correct answer: The most appropriate management for a patient with congestive heart failure is to administer diuretics to help remove excess fluid and monitor fluid balance. Diuretics help reduce the workload on the heart and alleviate symptoms of fluid overload. Choice B is incorrect because patients with congestive heart failure are usually advised to limit sodium intake and carefully monitor fluid intake. Choice C is incorrect because although oxygen therapy may be necessary in certain cases, it is not the primary management for congestive heart failure. Pain relief is not a primary intervention for this condition. Choice D is incorrect because bronchodilators are not the first-line treatment for congestive heart failure. Encouraging mobility is important, but administering diuretics and monitoring fluid balance take precedence in managing this condition.

5. A home health nurse is preparing for an initial visit with an older adult client who lives alone. Which of the following actions should the nurse take first?

• A. Educate the client about their current medical diagnosis.
• B. Refer the client to a meal delivery program.
• C. Identify environmental hazards in the home.
• D. Arrange transportation for the client to follow-up appointments.

Correct answer: C

Rationale: Identifying environmental hazards in the client's home is the priority during the initial visit with an older adult living alone. This action is crucial to prevent accidents, falls, and ensure the client's safety. While educating the client about their medical diagnosis, referring them to a meal delivery program, and arranging transportation for follow-up appointments are essential, addressing environmental hazards takes precedence as it directly impacts the client's immediate safety and well-being.

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