Nursing Elites

1. The charge nurse observes a new nurse preparing to insert an intravenous (IV) catheter. The new nurse has gathered supplies, including intravenous catheters, an intravenous insertion kit, and a 4x4 sterile gauze dressing to cover and secure the insertion site. What action should the charge nurse take?

• A. Instruct the nurse to use a transparent dressing over the site
• B. Allow the new nurse to proceed with the procedure
• C. Assist the new nurse with the insertion
• D. Replace the 4x4 gauze with a larger dressing

Correct answer: A

Rationale: The correct answer is to instruct the nurse to use a transparent dressing over the site. Transparent dressings allow for continuous observation of the IV site, reducing the risk of complications. Choice B is incorrect because the charge nurse should intervene to ensure the new nurse follows best practices. Choice C is incorrect as the charge nurse should not just assist but provide guidance on the correct procedure. Choice D is incorrect because the size of the dressing is not the issue; it's the type of dressing that allows for better observation.

2. The nurse is assessing a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which assessment finding requires immediate intervention?

• A. Elevated blood pressure
• B. Increased fatigue
• C. Headache
• D. Elevated hemoglobin

Correct answer: A

Rationale: The correct answer is A: Elevated blood pressure. In a client with chronic kidney disease (CKD) receiving erythropoietin therapy, elevated blood pressure requires immediate intervention. This finding is concerning as it may indicate worsening hypertension, which can lead to further complications. Increased fatigue (choice B) is common in CKD but may not require immediate intervention unless severe. Headache (choice C) can be a symptom to monitor but does not pose an immediate threat like elevated blood pressure. Elevated hemoglobin (choice D) is actually a desired outcome of erythropoietin therapy and does not require immediate intervention.

3. The nurse is administering an IV medication to a client with a history of anaphylaxis. Which intervention is most important for the nurse to implement?

• A. Stay with the client throughout the infusion.
• B. Keep emergency resuscitation equipment at the bedside.
• C. Obtain the client's allergy history.
• D. Ask the client about past allergic reactions to medications.

Correct answer: B

Rationale: Keeping emergency resuscitation equipment at the bedside is crucial in case the client experiences anaphylaxis during the infusion. While staying with the client throughout the infusion (Choice A) is important, having immediate access to emergency equipment takes priority in this situation. Obtaining the client's allergy history (Choice C) and asking about past allergic reactions to medications (Choice D) are relevant but do not address the immediate need for emergency intervention in case of anaphylaxis.

4. Which assessment is most important for the nurse to include in the daily plan of care for a client with a burned extremity?

• A. Distal pulse intensity
• B. Skin integrity
• C. Pain levels
• D. Range of motion

Correct answer: A

Rationale: The correct answer is A: Distal pulse intensity. Monitoring distal pulses is crucial to ensure that circulation to the extremity is not compromised. This assessment helps in detecting any signs of decreased circulation, which is vital in managing a burned extremity. While skin integrity (choice B), pain levels (choice C), and range of motion (choice D) are also important assessments, monitoring distal pulse intensity takes precedence as it directly reflects the perfusion status of the affected extremity in a burned client.

5. A client with a history of chronic alcoholism is admitted with confusion, ataxia, and diplopia. Which nursing intervention is a priority for this client?

• A. Monitor for signs of alcohol withdrawal.
• B. Administer thiamine as prescribed.
• C. Provide a quiet environment to reduce confusion.
• D. Initiate fall precautions.

Correct answer: B

Rationale: The correct answer is to administer thiamine as prescribed. This intervention is a priority for clients with chronic alcoholism to prevent Wernicke's encephalopathy, a serious complication of thiamine deficiency. Monitoring for signs of alcohol withdrawal (choice A) is important but not the priority in this scenario. Providing a quiet environment (choice C) may be beneficial but does not address the immediate need to prevent Wernicke's encephalopathy. Initiating fall precautions (choice D) is also important but not the priority compared to administering thiamine to prevent a life-threatening condition.

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