Nursing Elites

1. A nurse is preparing to assist a provider with the insertion of a nontunneled percutaneous central venous catheter into a client’s subclavian vein. Which of the following actions should the nurse take?

• A. Position the client in a high-Fowler’s position
• B. Place the client in Trendelenburg position
• C. Place a rolled towel under the client’s neck
• D. Assist the client into a side-lying position

Correct answer: B

Rationale: The correct action for the nurse to take when assisting with the insertion of a nontunneled percutaneous central venous catheter into the subclavian vein is to place the client in Trendelenburg position. This position helps distend the veins and reduces the risk of air embolism during the insertion procedure. Option A, positioning the client in a high-Fowler’s position, would not be appropriate as it does not facilitate venous distention. Option C, placing a rolled towel under the client’s neck, is not directly related to the procedure and does not serve a specific purpose in this context. Option D, assisting the client into a side-lying position, is also not the correct choice as Trendelenburg position is preferred for this procedure to aid in vein distention.

2. A nurse is preparing to perform a sterile dressing change for a client who has a surgical wound. Which of the following actions should the nurse take to prevent contamination during the dressing change?

• A. Use sterile gloves only as necessary
• B. Restart the procedure if the sterile solution splashes onto the sterile field while pouring the solution into the dressing tray
• C. Keep the dressing tray on a nearby surface
• D. Avoid speaking during the procedure

Correct answer: B

Rationale: The correct action to prevent contamination during a sterile dressing change is to restart the procedure if the sterile solution splashes onto the sterile field while pouring the solution into the dressing tray. Any contact with the sterile field by non-sterile items makes the field contaminated and requires restarting the procedure to maintain sterility. Choice A is incorrect because sterile gloves should always be used during a sterile procedure to prevent contamination. Choice C is incorrect as the dressing tray should be placed on a sterile surface, not on the client's bed, to maintain sterility. Choice D is also incorrect as talking during the procedure does not necessarily lead to contamination if proper aseptic technique is maintained.

3. A client at 38 weeks gestation with a history of herpes simplex virus 2 is being admitted. Which of the following questions is most appropriate to ask the client?

• A. Have your membranes ruptured?
• B. Do you have any active lesions?
• C. Are you positive for beta strep?
• D. How far apart are your contractions?

Correct answer: B

Rationale: The most appropriate question to ask a client with a history of herpes simplex virus 2 at 38 weeks gestation is whether they have any active lesions. Active herpes lesions during labor can necessitate a cesarean delivery to prevent neonatal transmission. Asking about ruptured membranes (choice A), beta strep status (choice C), or contraction timing (choice D) is important but not the priority when managing a client with a history of herpes simplex virus 2 due to the high risk of neonatal transmission.

4. A healthcare professional is verifying nasogastric tube placement by the pH of aspirated gastric fluid. Which of the following pH values provides a good indication of correct tube placement?

• A. 2
• B. 5
• C. 7
• D. 9

Correct answer: A

Rationale: The correct answer is A: '2'. Gastric contents with a pH between 0 and 4 provide a good indication of appropriate tube placement. A pH of 2 is within this range, indicating that the tube is correctly placed in the stomach. Choices B, C, and D are incorrect because a pH of 5, 7, or 9 does not fall within the expected acidic pH range of gastric fluid.

5. A nurse is providing discharge instructions to a client following a below-the-knee amputation. Which of the following instructions should the nurse include?

• A. Avoid sitting in a chair for prolonged periods.
• B. Sleep with a pillow under the residual limb.
• C. Elevate the limb continuously for the first 48 hours.
• D. Apply lotion to the residual limb daily.

Correct answer: A

Rationale: The correct answer is to instruct the client to avoid sitting in a chair for prolonged periods. This is important to prevent contractures from developing in the residual limb. Sleeping with a pillow under the residual limb can contribute to contracture formation rather than prevent it. While elevation of the limb is important for reducing swelling and promoting circulation, continuous elevation for 48 hours is not necessary and may not be practical. Applying lotion to the residual limb daily is generally not recommended immediately post-amputation as the wound site needs to heal without interference from lotions or creams.

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