Nursing Elites

1. The nurse is monitoring a client's intravenous infusion and observes that the venipuncture site is cool to the touch, swollen, and the infusion rate is slower than the prescribed rate. What is the most likely cause of this finding?

• A. The solution's rate is too rapid
• B. The client has phlebitis
• C. The infusion site is infected
• D. The infusion is infiltrated

Correct answer: D

Rationale: The correct answer is D. An infiltrated IV occurs when fluid leaks into the surrounding tissue, causing coolness, swelling, and a slow infusion rate. Choice A is incorrect because a rapid solution rate does not typically cause these specific symptoms. Choice B, phlebitis, presents with redness, warmth, and tenderness along the vein, not coolness. Choice C, infection, usually manifests with redness, warmth, and possibly purulent drainage, not coolness and swelling.

2. A client begins taking an antidepressant drug during the second day of hospitalization. Which assessment is most important for the nurse to include in this client's plan of care while the client is taking the antidepressant?

• A. Appetite
• B. Mood
• C. Withdrawal
• D. Energy level

Correct answer: B

Rationale: Corrected Rationale: Monitoring the client's mood is essential when starting an antidepressant to assess for any changes or adverse effects related to the medication. Changes in mood can indicate the effectiveness of the antidepressant or potential side effects. Assessing appetite (Choice A) is important but not as crucial as monitoring mood in this context. Withdrawal symptoms (Choice C) are more relevant when discontinuing antidepressants rather than starting them. Energy level (Choice D) can be influenced by various factors and may not directly reflect the client's response to the antidepressant.

3. When caring for a client with a tracheostomy, what is the most important assessment to perform?

• A. Check the client's oxygen saturation
• B. Assess the tracheostomy site for signs of infection
• C. Monitor the client's respiratory rate
• D. Ensure the tracheostomy ties are secure

Correct answer: A

Rationale: The most important assessment to perform when caring for a client with a tracheostomy is to check the client's oxygen saturation. This assessment is crucial as it ensures that the client is receiving adequate oxygen through the tracheostomy. Monitoring oxygen saturation provides immediate information on the client's respiratory status and the effectiveness of the airway management. Assessing the tracheostomy site for signs of infection is important but not as critical as ensuring adequate oxygenation. Monitoring the respiratory rate is also essential but does not directly assess the effectiveness of oxygenation. Ensuring tracheostomy ties are secure is important for maintaining the device but does not directly evaluate the client's oxygenation status.

4. The nurse is caring for a client with an indwelling urinary catheter. What is the most important action to prevent catheter-associated urinary tract infections (CAUTI)?

• A. Perform hand hygiene before and after handling the catheter
• B. Change the catheter every 72 hours
• C. Apply antibiotic ointment at the insertion site
• D. Irrigate the catheter daily

Correct answer: A

Rationale: Performing hand hygiene before and after handling the catheter is crucial in preventing catheter-associated urinary tract infections (CAUTI). This practice helps minimize the risk of introducing harmful microorganisms into the urinary tract. Changing the catheter every 72 hours is not recommended unless clinically indicated as it can increase the risk of infection. Applying antibiotic ointment at the insertion site is not a standard practice and may contribute to antibiotic resistance. Irrigating the catheter daily is unnecessary and can introduce pathogens into the urinary tract, increasing the risk of infection.

5. The nurse is assessing a client with a suspected diagnosis of deep vein thrombosis (DVT). Which clinical sign is most indicative of DVT?

• A. Redness and warmth over the affected area
• B. Decreased peripheral pulses
• C. Cyanosis of the toes
• D. Muscle cramps in the calf

Correct answer: A

Rationale: Corrected Rationale: Redness and warmth over the affected area are classic signs of inflammation, which commonly occur in deep vein thrombosis (DVT) due to the obstruction of blood flow. These symptoms result from the body's inflammatory response to the blood clot. Choices B, C, and D are less indicative of DVT. Decreased peripheral pulses may occur in arterial insufficiency rather than DVT. Cyanosis of the toes indicates decreased oxygenation and is more characteristic of arterial issues. Muscle cramps in the calf are nonspecific and can be caused by various conditions, not solely DVT.

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