Nursing Elites

1. The healthcare provider assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What should the healthcare provider do next?

• A. Apply a warm compress proximal to the site.
• B. Check for kinks in the tubing and raise the IV pole.
• C. Adjust the tape that stabilizes the needle.
• D. Flush with normal saline and recount the drop rate.

Correct answer: B

Rationale: In this scenario, the appropriate next step for the healthcare provider is to check for kinks in the tubing and raise the IV pole. These issues can commonly cause a slowed IV rate. Applying a warm compress (Choice A) may not address the underlying problem of kinked tubing or incorrect IV pole height. Adjusting the tape that stabilizes the needle (Choice C) is important for securement but is not the priority in this situation. Flushing with normal saline and recounting the drop rate (Choice D) should only be done after ruling out mechanical issues like kinks in the tubing.

2. The nurse is preparing to administer 2 units of packed red blood cells (PRBCs) to a client. Which action should the nurse implement to ensure the client’s safety?

• A. Obtain informed consent from the client for the PRBC transfusion
• B. Review the client’s medical history for a history of transfusion reactions
• C. Assess the client’s baseline vital signs before starting the transfusion
• D. Verify the blood type and crossmatch with another licensed nurse

Correct answer: D

Rationale: Verifying the blood type and crossmatch with another licensed nurse is crucial to prevent transfusion reactions and ensure the client's safety. This step helps confirm that the correct blood type is being transfused to the client, reducing the risk of adverse reactions and promoting safe care. Obtaining informed consent (Choice A) is important but not directly related to ensuring the safety of the transfusion. Reviewing the client's medical history for transfusion reactions (Choice B) is relevant but not as crucial as verifying the blood type and crossmatching. Assessing baseline vital signs (Choice C) is a routine practice before transfusion but ensuring the correct blood type is a higher priority.

3. What action should the nurse take after applying gloves to irrigate a client's indwelling urinary catheter using an open technique?

• A. Empty the client's urinary drainage bag.
• B. Draw up the irrigating solution into the syringe.
• C. Secure the client's catheter to the drainage tubing.
• D. Use aseptic technique to instill the irrigating solution.

Correct answer: B

Rationale: After applying gloves to irrigate an indwelling urinary catheter using an open technique, the next step for the nurse is to draw up the irrigating solution into the syringe. This step is crucial as it ensures that the solution is ready to be instilled through the catheter to maintain its patency and prevent blockages. Option A is incorrect as emptying the client's urinary drainage bag is not the immediate next step in the irrigation process. Option C is incorrect as securing the client's catheter to the drainage tubing is not necessary at this stage. Option D is incorrect as the question pertains to the action immediately after applying gloves and does not involve instilling the irrigating solution yet.

4. A client with a diagnosis of asthma is receiving albuterol (Proventil) via a metered-dose inhaler (MDI). Which assessment finding indicates that the medication is effective?

• A. Increased oxygen saturation.
• B. Decreased respiratory rate.
• C. Absence of audible wheezing.
• D. Improved exercise tolerance.

Correct answer: A

Rationale: Increased oxygen saturation (A) is the most direct indicator of the effectiveness of albuterol (Proventil) in improving breathing. Oxygen saturation reflects the amount of oxygen in the blood, showing that the albuterol is helping with air exchange in the lungs. While decreased respiratory rate (B), absence of audible wheezing (C), and improved exercise tolerance (D) are positive outcomes, they are secondary to oxygen saturation. Oxygen saturation directly reflects the improvement in the client's respiratory status and the effectiveness of the medication.

5. When making the bed of a client who needs a bed cradle, which action should the nurse include?

• A. Teach the client to call for help before getting out of bed.
• B. Keep both the upper and lower side rails in a raised position.
• C. Keep the bed in the lowest position while changing the sheets.
• D. Drape the top sheet and covers loosely over the bed cradle.

Correct answer: D

Rationale: A bed cradle is used to keep the top bedclothes off the client, so the nurse should drape the top sheet and covers loosely over the cradle. This helps in maintaining the proper positioning and function of the bed cradle to ensure the client's comfort and safety during bed making.

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