Nursing Elites

1. After placement of a left subclavian central venous catheter (CVC), the nurse receives a report of the X-ray findings indicating that the CVC tip is in the client's superior vena cava. Which action should the nurse implement?

• A. Remove the catheter and apply direct pressure for 5 minutes.
• B. Initiate intravenous fluids as prescribed.
• C. Secure the catheter using aseptic technique.
• D. Notify the healthcare provider of the need to reposition the catheter.

Correct answer: B

Rationale: Initiating intravenous fluids as prescribed is the appropriate action when the CVC tip is correctly placed in the superior vena cava. Intravenous fluids can now be administered effectively through the central line. Removing the catheter and applying direct pressure is unnecessary and not indicated as the tip is in the correct position. Securing the catheter using aseptic technique is important for preventing infections but is not the immediate action needed in this situation. Notifying the healthcare provider of the need to reposition the catheter may delay necessary fluid administration, which is the priority at this time.

2. The nurse is caring for a client with a chest tube after thoracic surgery. What is the most important assessment related to the chest tube?

• A. Ensure continuous bubbling in the water seal chamber
• B. Measure the amount of drainage every shift
• C. Keep the drainage system at the level of the chest
• D. Assess for subcutaneous emphysema around the insertion site

Correct answer: D

Rationale: The most important assessment related to a chest tube after thoracic surgery is to assess for subcutaneous emphysema around the insertion site. Subcutaneous emphysema can indicate air leakage from the pleural space, which can lead to serious complications such as a pneumothorax. Ensuring continuous bubbling in the water seal chamber is not the most critical assessment as it is a normal finding in a chest drainage system. While measuring the amount of drainage is important to monitor the client's condition, it is not as crucial as assessing for subcutaneous emphysema. Keeping the drainage system at the level of the chest helps maintain proper function but is not the most critical assessment in this scenario.

3. The client is being taught about a low-sodium diet. Which food should the client avoid?

• A. Fresh fruits
• B. Canned vegetables
• C. Fresh chicken
• D. Unsalted nuts

Correct answer: B

Rationale: The correct answer is B: Canned vegetables. Canned vegetables are often high in sodium due to the preservation process, so they should be avoided on a low-sodium diet. Fresh fruits (choice A), fresh chicken (choice C), and unsalted nuts (choice D) are all low-sodium options and can be included in a low-sodium diet. It is important to choose fresh or frozen vegetables over canned ones to reduce sodium intake. Fresh chicken and unsalted nuts are also good protein sources that are naturally low in sodium, making them suitable for a low-sodium diet. Therefore, clients following a low-sodium diet should prioritize fresh, whole foods over processed or canned options.

4. A client with type 1 diabetes is experiencing symptoms of hypoglycemia. What is the nurse's priority intervention?

• A. Administer glucagon intramuscularly
• B. Provide a complex carbohydrate snack
• C. Administer 50% dextrose intravenously
• D. Give 15 grams of a fast-acting carbohydrate

Correct answer: D

Rationale: The priority intervention for a client with type 1 diabetes experiencing symptoms of hypoglycemia is to give 15 grams of a fast-acting carbohydrate. In a hypoglycemic state, the priority is to quickly raise the blood glucose level. Administering glucagon intramuscularly (Choice A) is reserved for severe hypoglycemia when the client is unable to take oral carbohydrates. Providing a complex carbohydrate snack (Choice B) is beneficial after the initial treatment of hypoglycemia to prevent recurrence. Administering 50% dextrose intravenously (Choice C) is a more invasive intervention typically done in a hospital setting for severe cases.

5. A new mother is at the clinic with her 4-week-old for a well-baby check-up. The nurse should tell the mother to anticipate that the infant will demonstrate which milestone by 2 months of age?

• A. Turns from side to back and returns
• B. Consistently returns smiles to mother
• C. Finds hands and plays with fingers
• D. Holds head up and supports weight with arms

Correct answer: B

Rationale: The correct answer is B because social smiling is a developmental milestone typically expected around 2 months of age. At this stage, infants start to engage more with their caregivers and show positive emotional responses. The other choices are incorrect. Choice A describes a motor skill that usually emerges later. Choice C involves more coordination and exploration, which is not typically seen by 2 months. Choice D relates to head control and arm strength, which also develop progressively but may not be fully achieved by 2 months.

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