Nursing Elites

1. A nurse is planning care for a client who is receiving hemodialysis via an AV fistula. Which of the following interventions should the nurse include in the plan of care?

• A. Avoid taking blood pressures on the arm with the AV fistula.
• B. Check the fistula site daily for pallor.
• C. Place a warm compress over the fistula site every 4 hours.
• D. Keep the client's arm elevated on two pillows.

Correct answer: A

Rationale: The correct intervention is to avoid taking blood pressures on the arm with the AV fistula. This is crucial to prevent complications such as damage to the fistula. Checking the fistula site for pallor is not as important as avoiding blood pressures on the affected arm. Placing warm compresses over the fistula site is not recommended as it can increase the risk of infection. Keeping the client's arm elevated on two pillows is not necessary for the care of an AV fistula.

2. A nurse is caring for a client who has pneumonia and new onset confusion. Which of the following actions should the nurse take first?

• A. Increase the client's oxygen flow rate
• B. Obtain the client's vital signs
• C. Administer an antibiotic
• D. Notify the provider

Correct answer: A

Rationale: Correct Answer: Increasing the client's oxygen flow rate should be the nurse's first action. Hypoxia is a common complication of pneumonia and can lead to confusion. Providing adequate oxygenation is essential in addressing hypoxia and improving the client's condition.\nOption B: Obtaining vital signs is important but addressing hypoxia takes precedence in the setting of new onset confusion.\nOption C: Administering an antibiotic is important for treating pneumonia but addressing hypoxia and confusion is the priority.\nOption D: Notifying the provider may be necessary but addressing the immediate physiological need of oxygenation should come first.

3. 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.

4. A healthcare professional is preparing to administer a blood transfusion. What is the healthcare professional's first action?

• A. Check the client's temperature
• B. Verify that the client's blood type matches the blood product
• C. Administer the blood through an IV push
• D. Ensure the blood is warmed before administration

Correct answer: B

Rationale: The healthcare professional's first action before administering a blood transfusion should be to verify that the client's blood type matches the blood product. This step is crucial to ensure compatibility and prevent potentially severe transfusion reactions. Checking the client's temperature (Choice A) is important but not the first action in this scenario. Administering the blood through an IV push (Choice C) is incorrect as blood transfusions are typically administered as a slow infusion. Ensuring the blood is warmed before administration (Choice D) is not the first action and is not a standard practice in blood transfusions.

5. A client is constipated and asks the nurse for advice. What should the nurse recommend?

• A. Administer a laxative to relieve discomfort
• B. Increase dietary fiber to promote bowel movements
• C. Advise the client to rest until symptoms resolve
• D. Encourage bed rest to allow bowel function to return

Correct answer: B

Rationale: The correct recommendation for constipation is to increase dietary fiber to promote bowel movements. Dietary fiber helps add bulk to the stool, making it easier to pass and promoting regular bowel movements. Administering a laxative (Choice A) is not the first-line recommendation and should be used cautiously due to potential side effects. Resting until symptoms resolve (Choice C) and encouraging bed rest (Choice D) are not effective interventions for relieving constipation.

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