Nursing Elites

1. A nurse on the IV team is conducting an in-service education program about the complications of IV therapy. Which of the following statements by an attendee indicates an understanding of the manifestations of infiltration? (Select all that apply.)

• A. “The temperature around the IV site is cooler.”
• B. “The rate of the infusion increases.”
• C. “The skin at the IV site is red.”
• D. “The IV dressing is damp.”

Correct answer: A

Rationale: The correct statement is: 'The temperature around the IV site is cooler.' Cooler temperature around the site is indicative of infiltration, where IV fluid leaks into the surrounding tissue, causing tissue swelling. The other options are incorrect: B) An increase in infusion rate is not a sign of infiltration; instead, it could indicate an issue with the infusion pump or the IV catheter. C) Redness around the IV site is more indicative of infection rather than infiltration. D) A damp IV dressing is more suggestive of a leak in the IV system, not infiltration.

2. After performing foot care, the nurse checks the medical record and discovers that the patient has a disorder on the sole of the foot caused by a virus. Which condition did the nurse most likely observe?

• A. Corns
• B. A callus
• C. Plantar warts
• D. Athlete's foot

Correct answer: C

Rationale: The nurse most likely observed plantar warts, which appear on the sole of the foot and are caused by the papillomavirus. Corns (Choice A) and calluses (Choice B) are areas of thickened skin caused by pressure or friction and are not typically associated with viruses. Athlete's foot (Choice D) is a fungal infection that usually affects the skin between the toes and is not caused by a virus like plantar warts.

3. Upon completing the admission documents, the nurse learns that the 87-year-old client does not have an advance directive. What action should the nurse take?

• A. Record the lack of advance directive on the chart
• B. Give information about advance directives
• C. Assume that the client wishes a full code
• D. Refer this issue to the unit secretary

Correct answer: B

Rationale: The correct action for the nurse to take is to give information about advance directives to the client. By providing this information, the nurse empowers the client to make an informed decision about their care preferences. Choice A is incorrect because simply recording the lack of advance directive does not address the client's need for information. Choice C is incorrect because assuming the client wishes a full code without discussing it with them is not appropriate and may not align with the client's wishes. Choice D is incorrect as the nurse should directly address the issue with the client rather than involving another staff member.

4. A client is receiving morphine via PCA infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device?

• A. I'll wait to use the device until it's absolutely necessary.
• B. I'll be careful about pushing the button too much to avoid an overdose.
• C. I should tell the nurse if the pain doesn't stop while I am using this device.
• D. I will ask my adult child to push the dose button when I am sleeping.

Correct answer: C

Rationale: Choice C is the correct answer because it demonstrates that the client understands the importance of communicating with the nurse if the pain persists while using the PCA device. This is crucial as it ensures proper pain management and monitoring. Choices A and B are incorrect because delaying the use of the device until necessary or being cautious about pushing the button too much do not necessarily reflect understanding of using the PCA device effectively. Choice D is incorrect as having someone else, like an adult child, push the dose button goes against the principle of the client self-administering the medication through the PCA device.

5. The healthcare professional is preparing to administer a tuberculin skin test. Which site is most appropriate for this injection?

• A. Deltoid muscle
• B. Vastus lateralis muscle
• C. Abdomen
• D. Inner forearm

Correct answer: D

Rationale: The inner forearm is the most appropriate site for administering a tuberculin skin test. This test requires an intradermal injection, which is administered just below the surface of the skin. The inner forearm provides a flat, easily accessible surface for this type of injection. Choices A, B, and C are incorrect because the tuberculin skin test should not be administered into a muscle (deltoid muscle or vastus lateralis muscle) or into the abdomen. The test requires precise placement within the dermal layer of the skin on the inner forearm to accurately assess for a reaction.

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