Nursing Elites

1. During an IV catheter insertion demonstration, which statement by a nurse indicates understanding of the procedure?

• A. “I will thread the needle into the vein at an angle of 10 to 30 degrees with the bevel up.”
• B. “I will insert the needle into the client’s skin at an angle of 10 to 30 degrees with the bevel up.”
• C. “I will apply pressure approximately 1.2 inches below the insertion site before removing the needle.”
• D. “I will select a vein in the antecubital fossa for IV insertion based on its size and easily accessible location.”

Correct answer: B

Rationale: The correct technique for IV catheter insertion involves inserting the needle at a 10 to 30-degree angle with the bevel up. This angle facilitates proper vein puncture, reduces the risk of complications, and minimizes trauma to the vein. Choice A is incorrect because threading the needle into the vein at an angle of 10 to 30 degrees with the bevel up is the correct technique, not threading it all the way into the vein. Choice C is incorrect because applying pressure 1.2 inches below the insertion site before removing the needle is not a standard step in IV catheter insertion. Choice D is incorrect because selecting the antecubital fossa vein solely based on its size and accessibility may not be the most appropriate criterion; vein selection should also consider factors like vein condition and patient comfort.

2. When demonstrating an empathic presence to a client, which of the following actions should the nurse take?

• A. Use an open posture
• B. Write down what the client says for accurate documentation
• C. Establish and maintain eye contact
• D. Nod in agreement with the client throughout the conversation

Correct answer: A

Rationale: Using an open posture is crucial when demonstrating empathy to a client. This body language conveys openness, understanding, and a willingness to listen, creating a safe space for the client to express themselves. Establishing and maintaining eye contact is also important as it fosters a sense of connection and validation for the client. Writing down what the client says is essential for accurate documentation and memory but does not directly contribute to demonstrating empathic presence. Nodding in agreement with the client throughout the conversation may show attentiveness, but it does not necessarily reflect empathy or active listening as it could be misinterpreted as simply agreeing with what is being said.

3. A client with heart failure is being taught by a nurse on reducing daily sodium intake. What is the most important factor in determining the client's ability to learn new dietary habits?

• A. The involvement of the client in planning the change
• B. The presence of a dietitian during the teaching
• C. The use of dietary supplements
• D. The client's family support

Correct answer: A

Rationale: The most crucial factor in the client's ability to learn new dietary habits is their involvement in planning the change. When clients actively participate in setting their dietary goals, they are more likely to commit to and adhere to the changes. This empowerment fosters a sense of ownership and responsibility, enhancing the chances of successful dietary modifications. The presence of a dietitian, use of dietary supplements, and family support, while beneficial, are not as critical as the client's active participation in planning the dietary changes.

4. Before administering the prescribed morphine sulfate to a client post-op following laparotomy who reports pain and dry mouth, what should the nurse do first?

• A. Measure the client's vital signs.
• B. Assess the client's pain level.
• C. Verify the morphine order with another nurse.
• D. Check the client's last dose of morphine.

Correct answer: A

Rationale: Before administering morphine sulfate, it is crucial to measure the client's vital signs to ensure that the client is stable and safe to receive the medication. This step helps identify any contraindications or abnormalities that could affect the administration of morphine. Assessing the client's pain level (choice B) is important, but ensuring the client's physiological stability takes precedence. Verifying the morphine order with another nurse (choice C) and checking the client's last dose of morphine (choice D) are important steps but are not the priority before administering the medication.

5. A charge nurse is assigning tasks to a nurse and assistive personnel for a group of clients. Which of the following tasks should the charge nurse delegate to the AP?

• A. Report ABG results to the provider
• B. Instruct a client about how to use an incentive spirometer
• C. Administer an enteral feeding to a client who has an established gastrostomy tube
• D. Monitor the color of a client’s urinary output

Correct answer: D

Rationale: The correct answer is D because monitoring the color of a client's urinary output is a task that can be safely delegated to assistive personnel. This task involves basic observation and does not require specialized nursing knowledge or skills. Choice A is incorrect because reporting ABG results to the provider requires interpretation and critical thinking skills typically performed by a nurse. Choice B is incorrect as instructing a client about how to use an incentive spirometer involves educating and assessing the client, which is a nursing responsibility. Choice C is incorrect as administering enteral feeding to a client with a gastrostomy tube requires nursing expertise to ensure proper technique and monitoring for complications.

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